The four phases of migraine attack & how to prevent, manage pain

A migraine is more than just a bad headache. It’s a disabling disease that affects 39 million people in the United States, according to the American Migraine Foundation. June is officially designated as National Migraine & Headache Awareness Month – a perfect time to shed light on the often-misunderstood nature of migraines and why the condition is considered a chronic illness.

Migraine onset is unmistakable. Symptoms vary from person to person, but excruciating head pain, nausea, brain fog, dizziness, and sensitivity to light and sound – sometimes for hours or days – are typical hallmarks.

By the numbers

• For more than 90% of those affected, migraine interferes with education, career or social activities.
• Migraine affects 1 in 4 households in the U.S. and more than 1 billion people around the world.
• More than 50% of migraine patients go undiagnosed.
• No two migraine experiences are the same.
• Migraine attacks usually start in a patient’s 20s and 30s. They become less common and less severe with age.
• Roughly 15% of women and 5% of men suffer from this recurrent, often lifelong condition.

Source: American Migraine Foundation

Keeping track of symptoms

Living with migraine can feel isolating, since this neurological condition often leads to incapacity or moderate or severe disability.

“Fortunately, the list of both acute relief and preventive treatments continues to grow. Although there’s no cure for migraines, usually the right medicines, combined with self-help remedies, work fairly well for many sufferers,” says neurologist Alan Zacharias, MD of Associated Neurologists.

“Careful joint decision-making with your doctor is needed. Together, you can often find ways to treat your migraine attacks and make them less frequent and severe.”

If you are concerned that you may have migraine, keep a diary of your most common symptoms, when they occur and typically for how long, along with triggers, so you can talk with your provider. The more specifics you can reference, the better. This way your care team can work with you to manage your migraine and develop the best treatment plan.

Four phases of a migraine

Migraine attacks have distinct phases and understanding them can help patients manage their condition. Symptoms that occur in phases one or two can serve as warning signs and indicate the need for someone to take medication right away.

Phase 1: Prodrome

• This pre-headache phase indicates a migraine is on the horizon.
• Typically lasts a few hours.
• Can be debilitating with substantial temporary disability.
• A 2023 study found the most common symptoms of this phase include:
  • Neck pain and stiffness
  • Vision changes
  • Dizziness and feeling lightheaded
  • Foggy thinking
  • Trouble concentrating
  • Moodiness and irritability
  • Fatigue
  • Excessive yawning or cravings for certain foods

Phase 2: Aura

• This stage is unique because it’s only experienced by 25 to 30% of people with migraine.
• A series of sensory disturbances or disruptions to language that range from seeing sparks, bright dots and zig zags to tingling on one side of the body or inability to speak clearly.
• Typically lasts five to 60 minutes.
• Can be alarming to experience.

Phase 3: Headache

• When the actual migraine pain presents itself, it’s on one or both sides of the head.
• Pain can shift from one side of the head to the other over the course of the headache or gradually begin on one side and then progressively involve the second side.
• Can last several hours or up to three days.
• In addition to throbbing or pounding head pain, the most common symptoms of this phase are nausea, vomiting, sensitivity to light or sound, confusion, inability to sleep, anxiety and irritability. “You don't have to have all of those for us to say it fits the criteria for migraine, but quite typically some will have at least one of those features,” says Dr. Zacharias.

Phase 4: Postdrome

• Commonly referred to as the “migraine hangover” phase.
• Like prodrome and aura phases, not every individual will experience this phase during every migraine attack or ever.
• Length of the phase can vary, but it can last from 24 to 48 hours.
• Symptoms within this phase include fatigue, body aches, trouble concentrating, dizziness and sensitivity to light.
• Try to avoid triggers like bright lights and strong smells.

Source: American Migraine Foundation

Migraine triggers

Factors and events that can set off an attack are called migraine triggers and vary patient to patient. They include:

• Alcohol (often red wine)
• Bright lights
• Caffeine (too much or withdrawal)
• Chocolate
• Exercise
• Fermented cheeses and cured meats
• Hormone changes during the menstrual cycle
• Lack of sleep
• Perfumes and strong odors
• Stress and anxiety
• Weather changes

“What's being understood now is it may be that we crave some of these items, such as chocolate, as the early manifestation of our migraine — that the craving may be part of the migraine itself rather than an actual trigger,” says Dr. Zacharias.

Treating an attack

A migraine treatment plan may include some or all these methods for stopping an attack. If a patient does have a prescription medication, Dr. Zacharias says it’s best to “go straight for the big guns” like Triptan, instead of starting with ibuprofen.

• Caffeine and sleep: Migraine sufferers often report that a strong cup of coffee or restful sleep can improve the headache.
• Over-the-counter drugs: NSAID (nonsteroidal anti-inflammatory) drugs such as acetaminophen and ibuprofen or combination NSAID-caffeine pills can help. Benadryl can also have a calming effect to sight and sound disturbances.
• Traditional prescription medications: Two types of medications that providers often prescribe first are triptans and ergotamine, which work by balancing the chemicals in the brain. According to Dr. Zacharias, these medications have some side effects that limit their use and are not suggested for those with heart disease or high blood pressure.
• Prescription lidocaine nasal: Nasal sprays or drops applied directly to nerves in the back of the nasal cavity appear to offer significant relief to migraine sufferers.
• Newer prescription medications for patients with cardiovascular risks: These newer agents tend to have fewer side effects and lack the cardiovascular concerns associated with some triptans. These include Calcitonin Gene-Related Peptides (CGRP inhibitors) or “gepants” and Ditans.
  “This class of medications has developed even further into oral, dissolvable, nasal, injectable and infusion options and has been quite the game changer for most patients with migraine, as well as the providers who serve these patients,” says neurologist Christy Young, MD of Associated Neurologists.
• “Rescue” drugs for extreme migraine pain. These include barbiturates, narcotics and IV infusions of anti-seizure medications.

Prevention strategies

“When you only treat attacks, they come back. The goal is to figure out a prevention ‘cocktail’ for sustainable relief,” says Dr. Zacharias.

Prevention strategies can include the following:

• Supplementssuch as magnesium citrate (400-600mg), riboflavin (400mg), feverfew (50-300mg) and CoQ 10 (300mg) have the most supportive data for effectiveness, according to Dr. Zacharias. However, the U.S. Food & Drug Administration (FDA) only regulates prescription medicines and not vitamin and mineral supplements. "Because of this, it's important to research supplement manufacturers to make sure they have a long track record of safety and quality,” he warns.
• Prescription medications, taken daily, can help prevent attacks. Many of these medications were designed to treat other health conditions such as depression or epilepsy. Some examples are antidepressants, seizure medications, blood pressure medications and botulinum toxin.
• Relaxation techniques such as biofeedback and cognitive behavioral therapy (CBT) can help calm the nervous system without drugs. Biofeedback involves learning how to monitor and control your body's responses to stress, which lowers heart rate and eases muscle tension. The goal of CBT is to change patterns of thinking or behavior that may increase or maintain headaches. There’s strong evidence that these options can reduce the frequency of attacks.

“Treatment for prevention of migraines can work for one person but may not work for another. About 60% of patients get a 50% reduction in frequency of migraine,” Dr. Zacharias states. “Sometimes we’ll need to use more than one treatment approach for prevention.”

Make an appointment

The Associated Neurologists office is located at 4801 Riverbend Road (Suite 200) in Boulder. To make an appointment with a member of the team, call 303-415-8800.