The Prodrome Phase of Migraine

Dealing with the often disabling headache phase can be a powerful motivator for people to seek medical attention.² But other, perhaps more subtle symptoms can occur between two and 48 hours before the headache begins.^1,3 These symptoms make up the prodrome phase, which takes place even before aura symptoms (like vision blurriness, defects, and disturbances) develop.

This prodrome phase is still being studied by scientists to determine what regions of the brain may be involved. The wide variety of symptoms that can present as prodrome offers researchers clues to what parts of the brain may be involved.^2,3

One study of more than 1,000 people with migraine found that 38.5 percent reported prodrome symptoms.⁴ Another study of over 2,000 people with migraine showed that 77 percent reported having at least one prodrome symptom.³ While the rate may vary widely between individual studies, it generally seems that increased awareness and education about prodrome symptoms over the years has likely contributed to more and more people recognizing and reporting these symptoms, which previously had been underreported.¹

In this article, we’ll discuss several of the most commonly reported prodrome symptoms. The more you know about these symptoms, the easier it will be to identify them if they occur early on in a migraine attack. From there, you can work with your doctor to come up with a plan, including steps you can take to help treat a migraine headache.

1. Mood Change

Across multiple scientific studies, mood change is consistently one of the most common prodrome symptoms reported by people living with migraine.^1,3 In a 2016 study of people with migraine, about a third of the 2,000 participants said they experienced mood changes before their headaches began.³

The types of mood changes reported in prodrome phase by people with migraine include the following:

• Irritability^1,2
• Anxiety²
• Apathy² (lack of interest or motivation)
• Elation¹ (happiness)
• Euphoria² (intense excitement)
• Depression¹
• Sadness²
• Hyperactivity²

If you notice that you often experience significant mood changes within two days before a migraine headache, check with your doctor to see if this could be an early symptom and to create a plan for how to address it.

2. Fatigue or Lethargy

People who experience prodrome symptoms frequently report experiencing fatigue or lethargy.^1,3 In fact, the 2016 study previously mentioned revealed that lethargy was the third most common prodrome symptom. Like mood change, lethargy was reported by about one-third of all participants.³ If you keep a migraine diary of your symptoms and notice that you’re logging fatigue hours to days before you log a headache, this may be a migraine prodrome symptom for you.

3. Neck Stiffness or Pain

People often note that they have a stiff or tense neck leading up to a migraine headache.^1,4 In a study, “neck pain or stiffness” was the most common warning symptom reported by over 6,000 people with migraine and pre-headache symptoms, affecting over half of this group.⁵ Several other studies have even identified neck stiffness as one of the symptoms that occur the closest to the onset of headache pain (within eight hours), along with nausea and trouble concentrating.²

If you feel discomfort or pain in your neck, especially without a change in physical activity, recording when you feel this sensation along with the timing of your next headache might provide a clue to predict headache onset.

4. Yawning

Another commonly reported early migraine attack symptom that may predict headache onset is increased yawning.¹ One study showed that yawning was one of the earliest of early symptoms, starting over 12 hours before headache pain began.² The same study also reported that yawning was one of the symptoms most likely to predict a coming headache.²

If you have other prodrome symptoms but haven’t experienced increased yawning before a headache, the 2015 study might offer an explanation. The results showed a significant difference in frequency of yawning associated with migraine with aura versus migraine without aura. People who had migraine with aura were much more likely to also have yawning before their headaches.⁴ So if you don’t get auras with your migraine attacks, you may be less likely to experience yawning as an early warning sign of head pain.

Predictably, increased yawning often occurs alongside fatigue or lethargy, but less obvious prodrome symptoms can also happen at the same time as yawning, like mood changes and food cravings.³

5. Food Cravings

Food cravings and increased sensory perception of light, sound, or smell can also be prodrome symptoms.⁴ In the previously mentioned 2016 study of over 2,000 people with migraine, more than 20 percent reported cravings.³ In the 2015 study of over 1,000 people with migraine, less than 10 percent had food cravings.⁴ Those percentages might seem low, but it’s possible that some people could mistake this symptom as a trigger for migraine attacks.

The third edition of the International Classification of Headache Disorders (ICHD-3) is an authoritative guide that helps medical providers diagnose different kinds of headaches. Food cravings are regarded as such a significant prodromal symptom that the ICHD-3 definition of prodrome mentions “unusual hunger and cravings for certain foods” before migraine pain.⁶

6. Urinary Changes

The bladder may seem to be a long way from the brain, but studies show that changes in urination can be an early sign of a migraine attack.² Producing large amounts of urine (called polyuria) and increased frequency of urination are well known to occur in the prodrome phase.^1,2 Increased thirst, another prodrome symptom, may be connected to these urinary changes.¹ Some scientists think that a hormone called antidiuretic hormone (ADH) and the hypothalamus, the part of the brain that produces ADH, may be involved in connecting these issues to migraine.¹

7. Nausea

After headache, nausea may be one of the symptoms people most often associate with migraine. But did you know that nausea can also be a feature of the prodrome phase?¹

Nausea can occur as a prodromal symptom in people who have migraine with or without aura, although it may be more frequent in those who experience auras.^1,4 Studies disagree on whether nausea is a good early predictor of a coming migraine headache, but it does appear that nausea is consistently one of the symptoms that happen closest to the pain (within eight hours before), similar to neck stiffness.² So if you and your doctor determine that feeling nauseated tends to signal a coming migraine headache, the head pain likely will start sooner rather than later.

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