Blau{8} has divided the migraine attack into five phases: the prodrome, occurring hours or days before the headache; the aura, which come immediately before the headache; the headache itself; the headache termination; and the postdrome. As pointed out by Silberstein and Lipton{9} "although most people experience more than one phase, no one particular phase is required for the diagnosis of migraine." These authors provide a description of the five phases which review the initial manifestations of migraine: Prodrome Premonitory phenomena occur in approximately 60% of migraineurs, often hours to days before the onset of headache. These phenomena include psychologic, neurologic, constitutional, and autonomic features. Psychologic symptoms include depression, euphoria, irritability, restlessness, mental slowness, hyperactivity, fatigue, and drowsiness. Neurologic phenomena include photophobia, phonophobia, and hyperosmia. The generalized or constitutional symptoms include a stiff neck, a cold feeling, sluggishness, increased thirst, increased urination, anorexia, diarrhea, constipation, fluid retention, and food cravings. Some patients just report a poorly characterized feeling that they know a migraine attack is coming. Aura An aura refers to the appearance of focal neurologic symptoms that proceed or even accompany an attack of migraine. Approximately 20% of migraine sufferers experience auras. Most aura symptoms develop over a course of five to twenty minutes and usually last less than sixty minutes. The aura can be characterized by visual, sensory, or motor phenomena, and may also involve language or brainstem disturbances. When a headache follows, it most often occurs within sixty minutes of the end of the aura. The appearance of isolated auras without headache is known as migraine dissociée. The most common aura is visual, previously termed classic migraine. It usually has a distribution in a single hemifield. Sensory disturbances involve one side of the body and are characterized by descriptions of numbness or tingling on the face and in the hand. Further neurologic symptomatology is discussed under the heading of migraine with prolonged aura and migrainous infarction. Headache Phase The typical migraine headache is unilateral and throbbing. It may be bilateral and constant at first and later become throbbing. As pointed out by Lipton and Stewart{10} pain is characterized as throbbing in 85% of patients. However, it should be noted that a throbbing headache is described in other types of headache.{11} The pain of migraine is almost always accompanied by other features such as anorexia. Nausea occurs in up to 90% of patients and vomiting occurs in about one-third of migraineurs.{10} Many patients experience photophobia, phonophobia, and osmophobia, and seek seclusion in a dark, quiet room. Additional generalized symptoms include blurry vision, nasal stuffiness, anorexia, hunger, tenesmus, diarrhea, abdominal cramps, polyuria (followed by decreased urinary output after the attack), facial pallor (or, less commonly, redness), sensations of heat or cold, and sweating.{9 } Localized edema of the scalp, the face, or the periorbital regions may occur; tenderness may occur and be particularly prominent. There may also be tenderness of the scalp, a special prominence of a vein or artery in the temple, or a stiffness or tenderness of the neck. Impaired concentration is common; memory impairment occurs less frequently. Depression, fatigue, anxiety, nervousness, and irritability are common. A sensation of faintness may be experienced. The IHS selects particular associated features as cardinal manifestations for diagnosis. Termination and Postdrome In the termination phase, the pain wanes. The patient, thereafter, may feel listless, tired, or "washed out" and not be themselves for 24 to 48 hours. Rarely patients feel unusually refreshed or euphoric after an attack, whereas it is more common to note depression and malaise.{9}