The main symptoms of migraine

Migraine is a neurological disorder characterised by a functional disturbance of the central nervous system and accompanied by recurrent, often one-sided headache attacks. According to the World Health Organization, migraine affects about 15% of the world's population, and among women aged 20–50 it is particularly common. The clinical picture of the disorder is not limited to pain alone; migraine is characterised by a multi-component symptom complex and has a considerable effect on the patient's quality of life.

The pathophysiological basis of migraine

In the pathogenesis of migraine, activation of the trigeminovascular system, the release of neuropeptides (in particular calcitonin gene-related peptide, CGRP) and dilation of the cerebral blood vessels play the main role. In addition, cortical spreading depression — that is, the successive depolarisation of nerve cells followed by their inhibition — is linked to the development of the migraine aura.

The main forms of migraine

Migraine is grouped into two main forms:

Migraine without aura — accounts for about 70–80% of cases.
Migraine with aura — is accompanied by visual, sensory or speech disturbances.

This distinction is important when assessing the symptoms and the clinical course.

The main symptom stages of migraine

The symptoms of migraine are assessed in four stages: prodrome, aura, headache and postdrome. Each of these stages is characterised by its own clinical features.

1. The prodrome stage

The prodrome stage occurs 12–48 hours before the headache and is seen in about 60% of patients. The following symptoms are noted at this stage:

Tiredness and drowsiness
A change in appetite (especially a craving for sweet food)
Tension in the neck and shoulders
Increased urine output and thirst
Impaired concentration and attention

These changes are linked to early neurobiochemical processes in the hypothalamus and the limbic system.

2. The aura stage

Seen in about 25–30% of patients with migraine with aura. Aura consists of neurological symptoms that arise from a transient and reversible dysfunction of the cerebral cortex. Aura usually lasts 5–60 minutes.

The most common aura symptoms are the following:

Visual aura: bright lights, zigzag lines, “blind spots” in the field of vision (scotoma)
Sensory aura: paraesthesia in the hand, face or tongue (disturbed sensation)
Speech disturbance: aphasia, that is, difficulty finding words
Motor aura: in rare cases, weakness in the limbs

3. The headache stage

The most characteristic stage of migraine is the headache. The pain is usually one-sided, throbbing and of moderate or high intensity.

The following symptoms are seen during the headache stage:

Pain on one side of the head (most often in the temple or around the eye)
Pain that becomes worse with physical activity
Nausea and vomiting
Light (photophobia) and sound (phonophobia) sensitivity
Reduced appetite and dizziness

At this stage the release of neuropeptides such as CGRP, substance P and neurokinin A plays an important role in the development of the pain.

4. The postdrome stage

After the headache, in about 80% of patients a postdrome stage is noted. At this stage patients feel “tired” or “drained”.

Additional symptoms include:

Difficulty concentrating
Mood swings
Residual pain in the neck and head
Drowsiness and a feeling of thirst

The diagnostic criteria for migraine

According to the International Classification of Headache Disorders, a diagnosis of migraine requires the following criteria to recur at least five times in total:

1. The headache must last 4–72 hours.
2. At least two of the following features must be present:
   One-sided location
   Throbbing pain
   Moderate or severe intensity
   Pain that increases with physical activity
3. One or both of the following symptoms are present:
   Nausea and/or vomiting
   Photophobia and phonophobia

Differential diagnosis

It is important to distinguish migraine from other types of headache. Most commonly, tension-type headache and cluster headache are the disorders it is differentiated from.

Migraine: One-sided, throbbing pain of moderate or severe intensity; nausea and photophobia are present.
Tension-type headache: Bilateral pain of a squeezing, pressing character; photophobia is usually absent.
Cluster headache: Deep, boring pain around the eye and forehead; accompanied by watering of the eye and a runny nose.