| |
Blau8
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 Lipton9 “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 Stewart10 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 wains. 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
Return to Migraine Chapter |
