Migraine attacks can be split into five separate stages:
prodrome
aura
headache
resolution
recovery phase
However, not all migraineurs get an identifiable prodrome, or an aura. Although theoretically these phases are supposed to be separate (especially, the aura separated from the headache) experience suggests that overlap between the phases is actually quite common.
Attacks can begin at any time. Often, of course, they are related to the timing of their trigger factors. It is not unusual for sufferers to wake with a migraine.
The Prodrome. (Present in some patients only.) It may be others who notice the prodromal features more than you because some migraine sufferers develop recognisable patterns of behaviour. You may get excitable and on edge, or be tired and yawning. There may be craving for food (which would fit in neatly with a food allergy as a (rigger). You may have fluid retention, or heightened perception. These prodromal features may last as much as twenty-four hours, with an average of ten hours. Recognising the prodrome can be important, because preventive medicines taken at this stage may abort the attack.
The aura. (The aura doesn’t occur in common migraine.) There may be disorders of vision, flashing lights in the eyes, blank parts of your visual field; or you may have numbness and tingling over parts of your body; or difficulty in speaking, with an inability to string words together properly.
Aura symptoms vary from person to person. In many people the aura consists solely of twinkling lights at the very edges of the visual field, but in more severe cases can involve zig-zag lines, semi-circular blind spots in the field of vision etc.
A typical visual aura can be descrcibed as follows: it will begin with blurred vision, which is actually a small ‘blind spot’ near the centre of vision, in both eyes, and in the same place in both visual fields. This begins to expand within a minute or two, often forming a semi-circle to the right or to the left. The edge of the semicircle is jagged, like the teeth of a large saw. This effect is called a fortification spectrum because of its similarity to the plan of medieval forts.
On the inside of this enlarging, jagged outline is a blind area. As the semi-circle becomes larger and larger, the saw-tooth edge becomes more angled and more irregular and the scintillations (flashes of light) in it become more obvious. The whole blind spot moves to one side and then disappears (more often to the right). Only then does the headache start.
At first the headache is not always on one side, and interestingly when it is onesided it is not always on the side opposite to the blind area. Inside the brain nearly everything is converted left to right, so your left brain controls the right side of the body, and vice versa. A blind spot in the right side of the field of view is related to problems in the left side of the part of the brain dealing with vision. Sometimes the visual aura leaves an ‘after-image’ reminiscent of a shattered windscreen.
The visual aura ranges from a few minutes to over an hour, but most frequently lasts about twenty minutes. It can also include numbness of the hands or face, double vision, and weakness on one side of the body.
The headache. Usually the visual symptoms have gone by now, to be replaced by pain on opening the eyes; photophobia (sensitivity to light) and phonophobia (sensitivity to noise) are common. There is often nausea and vomiting. Note again how some of the symptoms change throughout the attack. Food cravings in the prodromal period may be replaced by nausea and then vomiting; this resolves gradually, passing through a phase when there is only limited tolerance to food. Similarly, the visual symptoms of migraine are in the aura phase, and when the headache takes over, these visual symptoms are replaced by photophobia with pain on opening the eyes.
In eighty per cent of cases the headache is one-sided; it is throbbing, and made worse by movement or straining. The face usually goes pale, and you may feel cold, especially in the hands and feet. During this time you will probably want to lie down in a quiet and darkened room. Light and noise may both be painful, and strong smells may cause nausea. During this time you may feel sleepy and yawn.
Intolerance of loud noise and dizziness often accompanies migraine. Sounds may be distorted and other people’s voices may sound unnatural and unreal. This magnification of sound is thought by some patients to indicate that their hearing has become more acute but, in fact, probably all they are suffering from is something called noise recruitment. In this case, there is actually a reduced ability to hear soft sounds, but the louder noises are magnified; in other words, a quiet whisper may not be heard at all, but a normal voice may sound as though the person is shouting.
There may be added noises and distortion of sounds, with roaring, rushing or hissing noises. These added sounds may occur during the attack, or during the aura. Very occasionally, deafness can occur, either in the aura, or during the headache. There is the possibility that repeated attacks of this nature can lead on to permanently reduced hearing, but deafness as a result of migraine is very rare.
Dizziness and vertigo (distortion in the sense of balance) are frequently associated with migraine. There are two forms: in the first the room appears to spin round (or else you feel as though you’re spinning round within the room) in the second, you experience strange and ill-defined feelings of floating or sinking, and of unsteadiness on walking. These sensations may be part of the aura, or during the headache itself. Outside the attack, a good proportion of migraine sufferers also suffer from motion sickness.
The resolution. Vomiting and sleep may herald the decline of the attack, but there is still a considerable degree of headache.
The recovery. After the main attack has subsided you will feel very fragile. It takes about thirty hours to get through this stage before you feel back to normal.
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