Rethinking Migraine

Part 2: The Four Phases of Migraine—Why the Headache Is Only One Part of the Story

Many people can feel their migraine coming on long before the pain begins. This isn't just an interesting observation—it's one of the keys to understanding migraine physiology.

One of the biggest paradigm shifts in migraine research over the past two decades has been the realization that the headache is only one phase of a much larger neurologic event.

For many patients, the headache is simply the point at which the migraine becomes impossible to ignore.

Research suggests that changes within the brain may begin hours—or even days—before the pain develops. For many patients, the migraine has already started long before they recognize it.

This understanding changes the way we think about migraine.

Instead of asking, "How do we treat the headache?" we begin asking, "What was happening in the nervous system before the headache ever appeared?"

Migraine Is a Process, Not an Event

Think of a tornado.

A tornado doesn't suddenly appear out of nowhere. Long before it touches the ground, atmospheric conditions have been changing. Warm and cold air collide. Wind patterns shift. Pressure changes. The tornado is simply the visible culmination of a process that has been building over time.

Migraine behaves much the same way.

The headache is often the most obvious symptom, but it isn't necessarily the beginning of the migraine.

The Four Phases of Migraine

Researchers now describe migraine as having four distinct phases:

1. 01

   Premonitory (Prodrome): Early neurologic changes that may begin up to 72 hours before the headache.

2. 02

   Aura: Transient neurologic symptoms experienced by some—but not all—migraine patients.

3. 03

   Headache: The phase most people recognize, characterized by activation of pain pathways within the trigeminovascular system.

4. 04

   Postdrome: The recovery phase, often marked by fatigue, brain fog, and lingering neurologic symptoms after the headache has resolved.

Not every patient experiences every phase, the phases may overlap, and the duration and intensity can vary considerably from one migraine to the next.

Listening for the Clues

One of the most valuable things we can do as clinicians is listen for symptoms that occur outside the headache itself.

Patients may casually mention that before every migraine they become unusually tired, crave chocolate, yawn repeatedly, develop neck stiffness, or simply "don't feel like themselves."

These are not random symptoms.

They're clues.

When we recognize migraine as a changing brain state rather than an isolated pain event, these seemingly unrelated symptoms begin to fit together.

Why This Matters for Acupuncturists

Acupuncturists are trained to recognize patterns rather than treat isolated symptoms.

Understanding the four phases of migraine encourages us to ask better questions, identify earlier warning signs, and appreciate that migraine is a dynamic neurologic condition—not simply an episode of head pain.

That shift in perspective often changes the entire clinical conversation and help us to understand the level of instability that may be present in the nervous system.

Looking Ahead

Each phase of migraine has its own fascinating physiology.

Why does the brain begin changing days before the headache?

What causes migraine aura?

Why does the weather make a difference?

How does the trigeminovascular system generate pain?

Why do so many patients feel exhausted after the headache is over?

We'll explore each of these questions in future articles throughout the Rethinking Migraine series.

References

1. Goadsby PJ, Holland PR, Martins-Oliveira M, Hoffmann J, Schankin C, Akerman S. Pathophysiology of Migraine: A Disorder of Sensory Processing. Physiological Reviews. 2017.
2. Charles A. The Pathophysiology of Migraine. The Lancet Neurology. 2018.
3. Schulte LH, May A. The Migraine Generator Revisited: Continuous Hypothalamic Activation Before the Headache Phase. Brain. 2016.

Continue Rethinking Migraine

Previous Article → Part 1: Migraine Is a Brain State, Not Just a Headache

Next Article → Part 3: Why Migraine Is More than Just a Vascular Disorder

This article is part of the series Rethinking Migraine. Subscribe to the newsletter for updates on articles, courses, and live events.

If you are looking for continuing education credits on this topic, consider my Migraine Series: A Clinical Guide for Acupuncturists available through Net of Knowledge!