The phases of a migraine attack: what happens from the first signs to the end

“I knew it in the morning. I was yawning as if I hadn’t slept for three days, everything irritated me, and in the afternoon I ate half a bar of chocolate. By evening it had arrived.”

People with migraine often describe an attack as if they were talking about a weather front they can feel coming a day ahead. Those around them see only part of the story: someone lying in a dark room who can’t bear even a quiet radio. They don’t see the day before, when that person was irritable and slow, or the day after, when the pain has gone but they feel as if they’ve been run over by a lorry.

In this post I will describe how a migraine attack unfolds from the first signs to the end, and what happens in the brain and to the person in each phase. I won’t recommend medication or make diagnoses — that belongs with your doctor and neurologist. But I will show where, in each phase, there is room for what you can do yourself: for understanding, for a plan, for a different conversation with yourself and with the people close to you.

An attack is not a moment but a cycle

First, a sentence I don’t want to leave out: migraine is a neurological disease, not a psychosomatic symptom. It is not the result of a weak character, suppressed emotions or not relaxing enough. It is a disease in which the brain processes sensory input differently, and it has a strong hereditary component. I described how it differs from an ordinary headache in more detail in Migraine is not just a bad headache: what the difference is and why it matters.

The International Classification of Headache Disorders and reviews of migraine mechanisms describe an attack as a sequence of phases: the prodrome or premonitory phase, in some people an aura, the headache phase and the postdrome, a kind of “hangover” after the attack. Between attacks there is a period specialists call interictal — but even then the brain is not entirely “quiet”, as its sensitivity rises and falls.

This view has an important consequence. The pain is not the beginning of the attack but its middle. Once you understand this, a lot changes — from how you read your own signs to what you blame yourself for.

Prodrome: the attack is under way, but the pain hasn’t come yet

The prodrome can begin a few hours, or even a day or two, before the pain. The most common signs people report in diary studies are tiredness, difficulty concentrating and a stiff neck. They may be joined by frequent yawning, irritability or low mood, sensitivity to light and sound, needing to pass urine more often, thirst and cravings for particular foods.

Why does this happen? An important part of the answer lies in the hypothalamus, the part of the brain that regulates sleep, appetite, body temperature and daily rhythms. In 2016 the German researchers Schulte and May published an unusual study: they scanned one person with migraine with magnetic resonance imaging every day for thirty days in a row, capturing three spontaneous attacks from start to finish. It turned out that the hypothalamus was more active, and connected differently to other parts of the brain, as early as the day before the pain. So the attack begins in the brain well before the person feels it as a headache.

From this follows something that is, for me, the most interesting part of the whole story. A review by Karsan and Goadsby points out that some “triggers” may in fact already be signs of the prodrome. If you have an irresistible craving for chocolate in the afternoon and a migraine in the evening, it is very easy to conclude that the chocolate caused the attack. But it may be exactly the other way round: the attack had already begun, the hypothalamus changed your appetite, and the craving for something sweet was its first messenger. The same goes for tiredness we put down to exertion, or sensitivity to light we put down to a screen.

This doesn’t mean triggers don’t exist. But it does mean it’s worth being cautious before you start forbidding yourself everything you ate or did the day before an attack — and before you start blaming yourself for having “caused” it.

Aura: when the brain shows something unusual

Aura occurs in a smaller share of people with migraine, roughly a quarter to a third, and not necessarily with every attack. The most common kind is visual: a shimmering zigzag line slowly spreading across the field of vision, spots, or a gap in part of the picture. There may be tingling that travels from the fingers towards the face, or difficulty finding the right words. According to the international classification, aura symptoms develop gradually, each lasts between five and sixty minutes, and they are fully reversible.

For someone experiencing it for the first time, aura is often more frightening than the pain itself. I explained what happens in the brain during it in Migraine with aura: what happens in the brain during aura. Here I’ll add just two practical points. First: if aura begins while you are driving, stop safely as soon as you can — don’t drive on with impaired vision. Second: a first aura in your life, an aura lasting more than an hour, or sudden weakness on one side of the body are reasons to be examined by a doctor, because similar signs can also occur with a stroke.

Headache phase: when everything is too much

The headache phase is the one everyone knows. In adults the pain is often one-sided and throbbing, but it can also involve the whole head. Without treatment it lasts between four and seventy-two hours. It comes with nausea or vomiting and with sensitivity to light, sound and often smells. That is why people withdraw to a dark, quiet room — not out of self-indulgence, but because every stimulus is an extra load.

During an attack many people also experience something those around them often don’t understand: touch becomes painful. Brushing hair, glasses, earrings, a pillow under the head or a partner’s hand on the shoulder can hurt. This is called allodynia, and a study by Burstein and colleagues linked it to increased sensitivity of the nerve pathways that carry pain during an attack. When someone with migraine moves away a hand that is trying to comfort them, it isn’t rejection. It is a nervous system set to maximum sensitivity for a few hours.

This phase also leaves the most room for thoughts that make the pain harder. “It will never end.” “I’ve ruined everything again.” “What if it’s something worse this time?” We call this flow of thoughts catastrophising. It doesn’t cause the pain, but it can increase suffering and the sense of helplessness. For many people anxiety wakes up too, in a body that is already overloaded — I described how anxiety plays out in the brain and why the body reacts before you think in What happens in the brain during anxiety — and why the body reacts before you think.

Postdrome: the “hangover” people rarely talk about

When the pain eases, the attack isn’t over yet. Many people describe a day or two of feeling exhausted, slowed down, foggy-headed and stiff in the neck. Some feel “empty”; more rarely, a short-lived euphoria appears. A study by Giffin and colleagues, in which people with migraine recorded their symptoms in an electronic diary, showed that the postdrome is a common part of an attack rather than an exception in a few individuals; the most frequently reported symptoms were tiredness, difficulty concentrating and a stiff neck.

The postdrome is psychologically interesting for a simple reason: those around you almost never see it. You are up again, no longer taking tablets, apparently healthy — so expectations quickly jump back to normal. And that is exactly when many people feel guilt and the pressure to make up for everything they missed. The work inbox, the housework, the children, the cancelled visit. You throw yourself at full pace with half your strength and feel incompetent because it isn’t working.

When it’s not migraine but a call to 112

Even someone who knows their phases well needs to know when a headache is not “their migraine”. Call 112 straight away (the emergency number in Slovenia and across the EU) if any of these appear:

• a sudden, extremely severe headache that peaks within seconds or a minute — “the worst headache of my life”;
• weakness or paralysis on one side of the body, a drooping corner of the mouth, slurred speech, confusion or loss of consciousness;
• a headache with fever and a stiff neck;
• a headache after a blow to the head, especially with drowsiness or vomiting;
• a headache with an epileptic seizure.

See a doctor as soon as possible if the pattern of your attacks changes noticeably, if an aura appears for the first time or lasts more than an hour, if a headache appears for the first time after the age of fifty or in pregnancy, or if a headache wakes you and gets worse when you cough or strain. The phases described in this post help you understand a known migraine — they are not a reason to put something new or different down to migraine without an examination.

What happens to the person between the phases

Every phase has a psychological side as well as a physical one. In the prodrome there is tense anticipation: will it start or not? In the aura, fear. During the headache, helplessness and often loneliness. In the postdrome, guilt and pressure. And between attacks many people are left with a quiet vigilance, a constant checking of the body. I described how this kind of inner radar works with other bodily signs in Health anxiety: when every symptom means the worst.

This is how a conversation the day after an attack might sound (composed, not a real person):

“Are you all right now? It doesn’t hurt any more, does it?”
“It doesn’t hurt. But I feel like a wrung-out rag. I can’t put a sentence together.”
“I thought we’d at least sort out the papers for the bank today.”
“I know. Sorry. I think I’ll manage tomorrow.”
“You don’t have to apologise. I just didn’t know it lasts another day afterwards.”

That last sentence is the key. Much of the tension in relationships affected by migraine comes from the fact that a partner, children or colleagues know only the middle of the attack. When they learn about the prodrome and postdrome, expectations become more realistic, cancellations feel less personal and conversations less accusing.

Exercise: draw a map of your phases

Once you can recognise your phases, an attack no longer arrives “out of nowhere”. That doesn’t mean you’ll be able to prevent it, but it does mean you’ll have a little more room for decisions. You can start this exercise today, even if you’re not having an attack right now.

1. Think back to your last two or three attacks and draw four columns on a sheet of paper: prodrome, aura, headache, postdrome. If you don’t have aura, leave that column empty.
2. In each column, write what you remember — physical signs, mood, thoughts, what you were doing. Don’t worry if a column is almost empty; many people have never paid attention to their prodrome.
3. Under each column, add one thing that helps you in that phase and one that harms you (for example: “in the postdrome I try to catch up on everything and collapse in the evening”).
4. Show the map to someone you live with and ask what they notice in you before an attack. Others often see the prodrome before we do.
5. At your next attack, add to the map in your diary. If you notice that observing yourself is pushing you into constantly checking your body, put it aside for a few weeks — the aim is understanding, not control.

For ongoing tracking, the knowledge base has a diary of bodily signs template. For moments of fear during an aura or at the start of the pain, breathing with a longer out-breath may help — not as a treatment for migraine, but as a way of letting the body settle a little when it’s frightened.

The map is useful at the doctor’s too. A description that includes what happens before and after the pain is far richer than “my head hurt again”, and it helps the doctor judge what treatment makes sense for you and when to use it.

Where this division doesn’t hold

Four phases make a useful map, but they are not an exact description of every attack. For many people they overlap: aura can start together with the pain or even after it, and the prodrome can be so subtle that it’s only recognised in hindsight. Some people never notice a prodrome; others have no distinct postdrome. There is no “correct” migraine you should be comparing yours to.

The second limit concerns my own advice. Once you know that an attack begins before the pain, it’s tempting to start checking your body constantly: is this yawn already a sign? Is this stiff neck the prodrome? For some people this kind of watching increases anxiety, and anxiety increases the perception of bodily signals — an ability called interoception turns from useful into exhausting. If you notice this happening, it’s a sign to reduce the observing, not increase it. And avoiding everything that might trigger an attack has its own cost, which I described in Anxiety and avoidance: why avoiding helps you today and harms you tomorrow.

And the third: understanding the phases is not treatment. If you have frequent or severe attacks, even the best map won’t replace an examination by your doctor and a plan you put together.

Between attacks: a life that isn’t just waiting

The longest phase of migraine is the one between attacks. And that is precisely where much is decided about how heavily migraine shapes your life. If between attacks you live in anticipation of the next one, cancel in advance and don’t dare plan anything, the illness spreads far beyond the days of pain.

In therapy with people who have migraine, we often work with exactly this space: how to plan with some slack rather than giving up on planning; how to tell those close to you what you need in each phase before an attack arrives; how to tell self-care apart from a fear that shuts you in. In relational family therapy, which I am training in, we are also interested in how migraine reshapes roles in a family — who takes over, who withdraws, who is left alone with anger they’re not allowed to show. Migraine is one person’s illness, but the relationships carry it together.

What to remember

• Migraine is a neurological disease; an attack is a cycle with a prodrome, aura in some people, a headache and a postdrome.
• An attack begins in the brain before the pain — some “triggers”, such as a craving for chocolate, may already be a sign of the prodrome.
• A sudden worst headache of your life, weakness on one side, speech problems, fever with a stiff neck or a first aura are reasons for urgent help (112) or an examination.
• The postdrome is part of the attack: half pace the day after the pain is not laziness.
• A map of your own phases helps you, those close to you and your doctor — as long as it doesn’t turn into constant checking of your body.