Migraines: More than Just Headaches
Decoding a four-phase neurological event 🧠
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A few weeks ago, a patient named Elena came to see me with a familiar story. She described severe headaches that had plagued her for years—throbbing pain on one side of her head, nausea, and sensitivity to light that forced her to retreat to a dark room for hours. But what caught my attention wasn't the headache itself, but what she mentioned almost as an afterthought.
She explained that she could sense the migraine coming a full day before the pain started. Food would taste different, and she'd experience visual disturbances with zigzag lines. Then after the pain finally subsided, she'd feel mentally foggy for another day, describing it as moving through molasses.
Elena had been treating her migraines as headaches—taking pain medication when the throbbing started and hoping for relief. But in our conversation, it became clear that what she was experiencing wasn't just a headache. It was a complex neurological event with distinct phases that extended well beyond the pain.
It makes sense why patients and doctors try to simplify common symptoms. Quick remedies for headache symptoms are widely available. Our time-constrained medical visits often make it challenging to address these complex neurological events with the nuance they deserve. Many of my patients experience this disconnect: they conceptualize migraines primarily as severe headaches, yet they intuitively sense there's something more extensive happening in their bodies beyond just the pain.
But what if we understand migraines not just as headaches, but as neurological events with distinct phases and opportunities for intervention?
The Neurological Symphony of a Migraine
Our understanding of migraines has evolved dramatically in recent decades. What was once considered primarily a vascular disorder (related to blood vessels) is now recognized as a complex neurological condition involving waves of electrical activity across the brain, inflammatory responses, and multiple neurotransmitter systems. Research has revealed a cascade of events including cortical spreading depression (waves of altered electrical activity moving across the brain's surface), activation of pain-sensing nerves, and release of inflammatory molecules that together create the migraine experience.
I explained to Elena that a migraine isn't just the headache—it's a four-phase neurological event:
First comes the prodrome, occurring 1-2 days before the headache, with subtle warning signs like mood changes, food cravings, neck stiffness, or increased thirst. About 70% of migraine sufferers experience this phase, though many don't recognize these as migraine-related symptoms.
Next is the aura phase, typically just before the headache, with sensory disturbances that affect about 25-30% of migraine sufferers. These can include visual phenomena like flashing lights or zigzag lines, sensory changes like tingling or numbness, or even difficulty speaking.
The headache phase itself lasts 4-72 hours and is what most people associate with migraines. It typically involves throbbing pain, often one-sided, frequently accompanied by nausea, vomiting, and sensitivity to light, sound, and sometimes smell.
Finally, the postdrome or "migraine hangover" can last up to a day after the headache resolves, bringing fatigue, difficulty concentrating, mood changes, and continued sensitivity to environmental stimuli.
When I walked Elena through this framework, she realized these symptoms weren't random but connected parts of a larger neurological process. For her and many patients, putting this scientific framework around their experience doesn't just validate symptoms—it provides a foundation for more effective treatment at each stage.
The traditional approach to migraines focuses almost exclusively on the headache phase, usually with medications aimed at relieving pain after it has already begun. While these treatments are important, viewing migraines as a multi-phase event reveals additional intervention points.
I worked with Elena to develop strategies for each phase of her migraines. During the prodrome, when she noticed early warning signs like food cravings and increased yawning, she could take preventative medication, hydrate aggressively, and maintain consistent sleep and meal times. When she experienced visual disturbances during the aura phase, she could take medication earlier when it's most effective and move to a quiet, dimly lit environment.
For the headache phase itself, Elena learned to combine medication with cold compresses and rest in a dark room. Even during the postdrome or "migraine hangover," she found value in staying hydrated and gradually returning to normal activities while documenting the entire episode to identify patterns.
Headache journals can do a lot to help patients connect the dot between triggers and pain.
The Challenge of a Neurological Approach
Despite the advances in our understanding, migraine remains challenging to treat for several reasons. As a primarily invisible condition, migraines are often underdiagnosed or dismissed. Many patients, particularly women, report feeling that their symptoms aren't taken seriously. The complexity of migraines means that treatment often requires a personalized approach—what works for one patient may not work for another.
The patients who fare best are those who find healthcare providers willing to acknowledge the full neurological spectrum of their migraine experience, collaborate on comprehensive treatment plans, and provide ongoing support as they navigate this chronic condition.
Key elements of this reimagined approach include:
Prioritizing prevention rather than just reacting to symptoms. For patients experiencing more than four migraine days monthly, preventive therapy deserves serious consideration. Elena, with her weekly migraines, found significant relief through preventive medication. Options range from traditional antihypertensives and antidepressants to newer biologics targeting specific neurological pathways.
Personal pattern recognition as an essential therapeutic tool. By tracking her experiences, Elena discovered her migraines often followed disrupted sleep and high work stress. This knowledge allowed her to implement targeted lifestyle adjustments during vulnerable periods, often preventing the full cascade of symptoms.
Elevating the mind-body connection from supplementary to primary care. Stress management, consistent sleep hygiene, and regular physical activity become core interventions rather than afterthoughts. For many migraine sufferers, these foundational practices significantly reduce both frequency and severity of episodes.
Empowering patients to become active participants rather than passive recipients of care. When Elena understood what was happening neurologically during each phase of her migraine, she gained confidence in recognizing early warning signs and implementing appropriate interventions.
Six months after our initial conversation about the neurological nature of migraines, Elena reported not only fewer migraine days but also decreased anxiety about when the next episode might strike. She no longer felt blindsided by her symptoms but equipped to cope with them.. This sense of informed control often makes the difference between feeling defined by migraines and feeling capable of managing them effectively.
QUESTIONS FOR YOU! 🙋🏻♀️
Have you noticed any symptoms before or after your headaches that might indicate they're actually migraines?
If you are a migraine sufferer, how have your symptoms been handled in various healthcare settings?
What strategies have helped you cope with your migraines?
I’m all ears!
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Disclaimer: The views expressed here are entirely my own. They are not a substitute for advice from your personal physician.
I experience my first migraine while pregnant with my first child. Then started having aura with my migraines at least 3 times a month. I'm 70 and have been dealing with migraines with aura for 40 years. I went to a new neurologist who suggested Botox injections on my neck and top of head. That was 10 weeks ago and I have not had one headache. Not one. I felt one "coming on" but it never materialized into an aura event. I'm ready for my next set of injections and I cannot say enough about them. It's been a miracle in my case. I'm not even obsessive of carrying a bottle of water with me to take Advil and Nuratec.
As a migraineur myself, it's been super helpful in relating to my patients. I went from classic migraines with vomiting that mimicked the exorcist, to perimenopausal changes that now lead to milder headaches. They run the gamut from what feels like neck muscle or tension headache, to dizziness, to profound fatigue. What always helps me identify it is that one side of my body feels normal and the other side hurts. I find that barometric pressure is a huge trigger - so I had rare migraines when living in Southern California, and frequent HA with the labile weather of DC. I have found that Riboflavin and magnesium glycinate supplements are helpful for prophylaxis without causing the GI side effects of mag oxide.
It's hard finding a neurologist, and more primary care doctors should educate themselves about migraine treatment. It is an exciting time in migraine treatment - so much more understanding of causes and so many options for treatment. They are very gratifying to treat!