The Stages of Migraines

by Guy McKhann, M.D.

July 5, 2011

There are some common neurological conditions that seem to fly under the radar in terms of re-search and attention. One of these is migraine.
As pointed out by Melinda Beck in The Wall Street Journal, migraines are a very common condition. In any given year, they occur in about 10-15 percent of males and 20-30 per-cent of females. Despite these numbers, the amount of money spent on research on migraine me-chanisms and treatment is miniscule compared to other much less common conditions such as AIDS, epilepsy, or stroke. (I am not implying that too much money is being spent on these con-ditions, just that migraines are being ignored.)

Migraines occur as attacks of severe headaches that usually cover half of the head. In fact the word “migraine” comes from the Greek, meaning “half skull.” Most attention is paid to the headache phase, but there are four phases which can occur:

The prodromal phase (referred to as “premonitory phase” in the Journal article), which occurs anywhere from a few hours to a day or two prior to the onset of the headache, is very varied among patients, but rather stereotyped for a given patient. In a dramatic example, I had a patient who was very much into music. She worked for a public TV station as a music coordinator and regularly attended concerts. Prior to a migraine attack, she could not stand listening to music. She remembers having to leave a concert early because the sound of the music was so disagreeable. She knew an attack of migraine was coming. This and the types of symptoms that are described in the article are probably more common than usually reported, in part because physicians don’t ask about them.

Another stage is the “aura” phase. The aura is part of the acute attack, occurring a few minutes before the headache, or co-incident with the headache. The most common symptoms are visual, such as flashing lights, or loss of areas of vision. Other sensory symptoms may occur such as tingling in an arm or side of the face. A particularly disturbing feature is when half of the body becomes paralyzed, so-called “hemi-plegic migraine.” The first time this happens, distinguishing this from a stroke can be difficult.

The headache phase is when the pain of the headache gradually builds, and can last for a day or two if untreated. Many patients also experience nausea, vomiting, inability to tolerate bright lights or loud sounds, and even disturbances in thinking. The traditional concept of a woman in bed in a darkened room with a wet cloth over her forehead is not exaggerated.

Many people do not just “snap out “of a migraine attack. They may feel tired or “hung-over,” a symptom of the postdromal phase. A feeling of depression is common. For those with more chronic migraines, fear of another attack can be quite unsettling.

Space does not allow discussion of the mechanism of migraines this time, but will be the basis of new approaches to treatment in a future column. Any discussion of treatment needs to include long-term treatment. Of those who start a particular treatment, how many are still including it one or two years later?

The ultimate goal is to prevent full-blown attacks. We are not there yet.