Migraine whispers
before it roars

In up to 72% of individuals, prodrome can predict the onset of some migraine headaches1,2
1. Gago-Veiga AB, Pagán J, Henares K, et al. To what extent are patients with migraine able to predict attacks? J Pain Res. 2018;11:2083-2094.
2. Karsan N, Goadsby PJ. Biological insights from the premonitory symptoms of migraine. Nat Rev Neurol. 2018;14(2):699-710.

This presents an opportunity to consider
early treatment, effectively avoiding
headache progression.

Uncover
prodrome insights

Understanding prodrome can help determine
how the migraine attack starts and evolves,
and can help identify an optimal treatment window.

When does
prodrome start

Symptoms typically start hours before the onset of migraine headache and are experienced by about 70% of individuals.2

How common is prodrome in migraine?

The prevalence of prodrome is likely underreported due to lack of patient and provider recognition and misinterpretation of symptoms as triggers.

Prodrome symptoms are experienced by about 70% of individuals.2

The
neurological
prelude

The presence of symptoms and altered brain physiology during the prodrome phase confirms the involvement of several brain areas before the onset of pain, rather than in response to pain.
3. Karsan N, Goadsby PJ. Biological insights from the premonitory symptoms of migraine. Nat Rev Neurol. 2018;14(2):699-710.

How can prodrome
be recognized?

Symptoms can be grouped into the following
broad categories3:

Difficulty concentratingDifficulty readingMemory complaintsDisorientationConfusionMood changes / depression • irritability • elation
Food cravingsThirstExcessive urinationChanges in alertnessAltered sleep-wake cycleYawning
Mild head discomfortPhotophobiaPhonophobiaOsmophobiaNeck painAllodyniaNausea
LacrimationNasal stiffnessRhinorrheaAural fullnessSensation of throat swelling
2. Karsan N, Goadsby PJ. Biological insights from the premonitory symptoms of migraine. Nat Rev Neurol. 2018;14(2):699-710.

Are your patients telling you about
their prodrome symptoms?

Empower your diagnostic process with our prodrome symptoms checklist.

Download and print this comprehensive tool for informed and precise assessments.

Prodrome Symptoms Checklist

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Explore all
migraine phases

Prodrome
Aura
Headache
Postdrome
Interictal

Prodrome

Phase duration:
48 hours or less1
Patients with
migraine experience
70%2

Understanding prodrome, the earliest phase of the migraine attack, can help determine how the migraine attack starts and evolves, and can help identify an optimal treatment window.

Symptoms typically start hours before the onset of migraine headache and are experienced by about 70% of individuals.2

Although some individuals with migraine report exogenous triggers (eg, foods, bright light, loud sounds) evidence suggests that these may be symptoms of abnormal sensory sensitivity due to prodrome.3

Prodrome may predict onset of some migraine headaches in up to 72% of individuals and may provide an opportunity to consider early treatment to avoid headache progression.3,4

The prevalence of prodrome is likely underreported due to lack of patient and provider recognition and misinterpretation of symptoms as triggers.

The presence of symptoms and altered brain physiology during the prodrome phase confirm the involvement of several brain areas before the onset of pain, rather than in response to pain.3

Prodrome prevalence rates have increased over time, suggesting that increasing awareness of prodrome through education increases reporting of symptoms.3

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Lipton B, Lanteri-Minet M, Leroux E, et al. Pre- and post-headache phases of migraine: multi-country results from the CaMEO - International Study. J Headache Pain. 2023;24(1):151.
3. Karsan N, Goadsby PJ. Biological insights from the premonitory symptoms of migraine. Nat Rev Neurol. 2018;14(2):699-710.
4. Gago-Veiga AB, Pagán J, Henares K, et al. To what extent are patients with migraine able to predict attacks? J Pain Res. 2018;11:2083-2094.
1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Lipton B, Lanteri-Minet M, Leroux E, et al. Pre- and post-headache phases of migraine: multi-country results from the CaMEO - International Study. J Headache Pain. 2023;24(1):151.
3. Karsan N, Goadsby PJ. Biological insights from the premonitory symptoms of migraine. Nat Rev Neurol. 2018;14(2):699-710.

Aura

Phase duration:
Less than 60 min1
Patients with
migraine experience
30%2

Aura consists of reversible neurological symptoms that may occur prior to, concurrently, or independent of a headache.

About 30% of people who experience migraine have attacks with aura.2

Most individuals with migraine with aura also have migraine headaches without aura.3

Aura is reversible and evolves gradually over time.1

Clinical presentation of migraine with aura varies considerably, both among individuals and between attacks in an individual.4

The presence or absence of aura does not always predict presence or absence of aura in future migraine attacks.3

Recognizing aura symptoms may help with proper diagnosis of reported symptoms to find the right treatment, and may help mitigate unnecessary neurodiagnostic testing.5,6

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Rasmussen BK, Olesen J. Migraine with aura and migraine without aura: an epidemiological study. Cephalalgia. 1992;12(4):221-228.
3. Hansen JM, Charles AC. Differences in treatment response between migraine with aura and migraine without aura: lessons from clinical practice and RCTs.J Headache Pain. 2019;20(1):96.
1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Rasmussen BK, Olesen J. Migraine with aura and migraine without aura: an epidemiological study. Cephalalgia. 1992;12(4):221-228.
3. Hansen JM, Charles AC. Differences in treatment response between migraine with aura and migraine without aura: lessons from clinical practice and RCTs.J Headache Pain. 2019;20(1):96.
4. Hansen JM, Goadsby PJ, Charles AC. Variability of clinical features in attacks of migraine with aura. Cephalalgia. 2016;36(3):216-224.
5. Viana M, Tronvik EA, Do TP, Zecca C, Hougaard A. Clinical features of visual migraine aura: a systematic review. J Headache Pain. 2019;20(1):64.
6. Evans RW, Burch RC, Frishberg, BM, et al. Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence-Based Guideline. Headache. 2020;60(2):318-336.

Headache

Phase duration:
4-72 hours1
Patients with
migraine experience
95%2

Experienced by about 95% of individuals, headache is the most recognized and disabling phase of the migraine attack. Headaches often involve moderate-to-severe pain that is throbbing or pulsing, typically on one side of the head.2

People with migraine often experience pain as well as other symptoms during this phase.2

While very uncommon, not all migraine attacks have the headache phase.2

Intervening early has been shown to result in improved outcomes.3,4

The throbbing pain of the headache phase is the result of the release of vasoactive neuropeptides, such as CGRP, causing trigeminovascular pathway activation. Understanding underlying mechanisms can help identify targeted treatments.3

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Migraine. MedlinePlus. Updated May 5, 2021. https://medlineplus.gov/migraine.html.
3. Foley KA, Cady R, Martin V, et al. Treating early versus treating mild: timing of migraine prescription medications among patients with diagnosed migraine. Headache. 2005;45(5):538-545.
4. Ailani J, Burch RC, Robbins MS on behalf of the Board of Directors of the American Headache Society. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039.
1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Migraine. MedlinePlus. Updated May 5, 2021. https://medlineplus.gov/migraine.html.
3. Dodick SW. A phase-by-phase review of migraine pathophysiology. Headache. 2018;58(suppl 1):4-16.

Postdrome

Phase duration:
48 hours or less1
Patients with
migraine experience
80%-94%2,3

Experienced by about 80%-94% of individuals2,3, postdrome is the constellation of symptoms occurring once the headache pain has subsided, often referred to as the “hangover phase.”4,5

There is no absolute marker for the end of the headache phase and the beginning of the postdrome.6

25.2 hours is the average duration of postdrome, which may be just as debilitating as the headache pain.4,7

More research is needed to evaluate treatment impact on postdrome, as it is one of the least studied phases of migraine.4

Individuals may continue to experience non-headache symptoms even after head pain has resolved. Functional imaging has shown widespread reduction in brain-blood flow in the postdrome phase.4

The migraine postdrome is the least understood and studied phase of the “migraine attack,” yet causes significant persistent disability. Effective treatment of migraine attack may help with symptom reduction, including postdrome, and improved quality of life.5

The phenotype of the postdrome seems less heterogeneous than the premonitory phase, with symptoms varying greatly. Individuals may fail to recognize these symptoms once their headache pain has been resolved.6

1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Giffin NJ, Lipton RB, Silberstein SD, Olesen J, Goadsby PJ. The migraine postdrome: An electronic diary study. Neurology. 2016;87;1-5.
3. Blau JN. Resolution of migraine attacks: sleep and the recovery phase. J Neurol Neurosurg Psychiatry. 1982;45(3):223-226.
4. Bose P, Goadsby PJ. The migraine postdrome Curr Opin Neurol. 2016;29(3):299-301.
5. Migraine Hangover. American Migraine Foundation. February 18, 2018. Accessed August 2022. https://americanmigrainefoundation.org/resource-library/migraine-hangover/.
6. Kelman L. The postdrome of the acute migraine attack. Cephalalgia. 2006;26(2):214-220.
7. Giffin NJ, Lipton RB, Silberstein SD, Olesen J, Goadsby PJ. The migraine postdrome: An electronic diary study. Neurology. 2016;87(3);309-313.
1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Giffin NJ, Lipton RB, Silberstein SD, Olesen J, Goadsby PJ. The migraine postdrome: An electronic diary study. Neurology. 2016;87;1-5.
3. Blau JN. Resolution of migraine attacks: sleep and the recovery phase. J Neurol Neurosurg Psychiatry. 1982;45(3):223-226.
4. Bose P, Karsan N, Goadsby PJ. The migraine postdrome. Continuum (Minneap Minn). 2018;24(4):1023-1031.
5. Bose P, Goadsby PJ. The migraine postdrome Curr Opin Neurol. 2016;29(3):299-301.
6. Karsan N, Peréz-Rodríguez A, Nagaraj K, Bose PR, Goadsby PJ. The migraine postdrome: Spontaneous and triggered phenotypes. Cephalalgia. 2021;41(6):721-730.

Interictal

Phase duration:
Varies1
Patients with
migraine experience
30%

The interictal phase is the period between migraine attacks.

The transition between the interictal phase and the migraine attack is poorly understood.2

Recognition of the interictal burden, beyond just headache, may help improve overall migraine management.3

According to a national online poll of 505 adults with migraine3:

45% feel that concern about another migraine attack is always in the back of their mind.

39% worry about disruptions to work and daily life.

37% always feel anxious about when the next migraine will strike.

32% worry about headache pain severity and suffering.

1. Katsarava Z, Buse DC, Manack AN, Lipton RB. Defining the differences between episodic migraine and chronic migraine. Curr Pain Headache Rep. 2012;16(1):86-92.
2. Peng KP, May A. Redefining migraine phases - a suggestion based on clinical, physiological, and functional imaging evidence. Cephalalgia. 2020;40(8):866-870.
3. Pinheiro CF, Moreira JR, Carvalho GF, et al. Interictal photophobia and phonophobia are related to the presence of aura and high frequency of attacks in patients with migraine. Appl Sci. 2021;11(6):2474.
1. Katsarava Z, Buse DC, Manack AN, Lipton RB. Defining the differences between episodic migraine and chronic migraine. Curr Pain Headache Rep. 2012;16(1):86-92.
2. Peng KP, May A. Redefining migraine phases - a suggestion based on clinical, physiological, and functional imaging evidence. Cephalalgia. 2020;40(8):866-870.
3. Brandes JL. The migraine cycle: patient burden of migraine during and between migraine attacks. Headache. 2008;48(3):430-441.
Phases may overlap or vary in incidence and impact.
Bar height represents the relative degree of impact on the daily life of a person with migraine. The depiction is an example only and each individual migraine cycle may look different.

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