The stages of migraine: from warning signs to recovery

A migraine attack usually has four stages: the prodrome (warning stage), the aura, the headache and the postdrome (recovery stage). Not everyone goes through every stage, and a whole attack can last from about 12 hours to 4 days. Recognising the stages of migraine helps you act earlier and lessen the impact of an attack.

A migraine attack is more than a headache that comes and goes. It is a complex process in the brain that unfolds in stages, often starting hours before the pain begins.

What happens in your brain during a migraine attack?

Migraine is an inherited brain condition. Your brain is thrown off balance more easily than in people without migraine, for example by hormonal changes, too little sleep or bright, intense stimuli.

During a migraine attack, the warning system in your brain becomes disrupted. The trigeminal nerve becomes active and causes inflammation around the blood vessels in the membranes surrounding the brain. This releases a substance called CGRP (calcitonin gene-related peptide). CGRP is a messenger molecule with a central role in migraine pain: it widens blood vessels and activates pain nerves, setting off a chain reaction of pain.

Modern migraine medicines such as the monoclonal CGRP inhibitors (erenumab, fremanezumab and galcanezumab) and the gepants (atogepant and rimegepant) were developed specifically to block this process.

What are the 4 stages of migraine?

A migraine attack usually runs through four stages, as described in the International Classification of Headache Disorders (ICHD-3). How long and how intense each stage is varies from person to person, and from attack to attack.

Stage 1: the prodrome (warning stage)

The prodrome is the first of the four stages of migraine. It starts hours, sometimes up to a day, before the headache. Your brain is in effect sending warning signals that it is losing its balance. Many people only recognise these signals afterwards.

Symptoms of the prodrome include:

• tiredness, or restlessness
• mood changes (irritability, feeling low)
• frequent yawning
• cravings for sweet or particular foods
• a stiff neck or shoulders
• difficulty concentrating

Recognising the prodrome is valuable: it gives you the chance to avoid stimuli and to be ready with your acute medication.

Stage 2: the aura

About one in three people with migraine have an aura. An aura is a temporary disturbance caused by a slow wave of electrical activity across the surface of the brain, called cortical spreading depression. It is a bit like a short circuit that spreads slowly.

Common aura symptoms:

• visual changes: flashes of light, zigzag lines, blind spots, blurred vision
• tingling in the face, hands or arms
• difficulty speaking or finding words

An aura usually lasts between 5 and 60 minutes and fades on its own. Auras are generally harmless, but they can be frightening, especially the first time. Not everyone with migraine has an aura, and the same person may have one with some attacks and not with others.

Stage 3: the headache

This is the most intense of the stages of migraine. The pain is usually throbbing or pounding, often on one side of the head, and gets worse with movement or effort.

Other symptoms during the headache stage:

• nausea or vomiting
• sensitivity to light (photophobia) and sound (phonophobia)
• sensitivity to smells
• pain when touching your head or hair (allodynia)
• problems thinking: forgetfulness, slower thinking, brain fog
• intense low mood, anxiety or feeling emotionally overwhelmed

The headache stage can last from 4 to 72 hours. This is when acute medication, such as a triptan, makes the difference: the earlier you take it, the better it tends to work.

Stage 4: the postdrome (recovery stage)

The postdrome is the last of the stages of migraine, and is often called the migraine hangover. Your brain has been through a kind of reset and needs time to recover. Many people underestimate this stage, but its impact can be considerable.

Symptoms of the postdrome:

• exhaustion and tiredness
• difficulty concentrating or brain fog
• feeling emotionally sensitive
• aching muscles
• sometimes, a feeling of relief or clarity

The postdrome lasts from a few hours to about a day. Allow yourself rest during this time. You are not being lazy: your brain is recovering from an intense process.

How long do migraines last?

A whole migraine attack, from prodrome to the end of the postdrome, can last from about 12 hours to as long as 4 days. The headache stage on its own lasts 4 to 72 hours when it is not treated. About 10 million people in the UK live with migraine, and for many of them the impact of each attack goes well beyond the hours of headache.

Why does it help to recognise the stages of migraine?

• Taking medication at the right time: acute medication works best when you take it early in the attack, not once the headache is at full strength.
• Spotting patterns: noting prodrome symptoms in a headache diary can help you discover patterns and triggers.
• Talking to your migraine specialist: the more precisely you can describe your stages, the more targeted your treatment can be.
• Knowing what to expect: knowing that the recovery stage is normal can ease feelings of guilt.

How is each stage of migraine treated?

Migraine treatment is not one size fits all. Ideally, the approach matches the stage:

• Prodrome: avoid stimuli, rest, and have your acute medication to hand.
• Aura: if you have migraine with aura, take your acute medication when the headache starts, after the aura.
• Headache: take your acute medication as early as possible. This can be a triptan, such as sumatriptan or rizatriptan, or a gepant (atogepant and rimegepant are the two gepants). Rest in a dark, quiet room.
• Postdrome: rest, drink enough, and give yourself time. Recovery takes time.

If you have more than 4 attacks every 4 weeks, preventive treatment can reduce the number of attacks. Options include the monoclonal CGRP inhibitors erenumab, fremanezumab and galcanezumab, and the gepants atogepant and rimegepant.

Frequently asked questions about the stages of migraine

How many stages does a migraine attack have?

Four: the prodrome (warning), the aura, the headache and the postdrome (recovery). Not everyone goes through every stage in every attack.

What is cortical spreading depression?

Cortical spreading depression is a wave of electrical activity that spreads slowly across the surface of the brain. It causes aura symptoms such as visual disturbances and tingling.

What should I do at the first signs of a migraine attack?

Avoid strong stimuli, rest, and take your acute medication as early as your migraine specialist has advised. The sooner you act, the better the medication tends to work.

How The Migraine Clinic can help

The Migraine Clinic focuses only on migraine. Our migraine specialists look at your own attack pattern: which stages you go through, how long they last and which treatment works best for each stage. Consultations are fully online by video, and you do not need a referral.

• Check your symptoms with the migraine test.
• Read about acute medication and preventive medication.
• See how to start.

This article was written by the medical team of The Migraine Clinic.