S1 E1: Four Stages of Migraine

A National Migraine Centre Heads Up Podcast transcript

Four Stages of Migraine

Series 1, episode 1

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[00:00:00] This is the launch of the Heads Up podcast and did you know it is also the fifth annual World Brain Day. This year it is dedicated to raising awareness for the most common brain disease in the world: migraine. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.

Dr Katy Munro [00:00:27] Hi, welcome to our Heads Up podcast. I’m Dr. Katy Munro from the National Migraine Centre and today I’m talking with my colleague, Dr Jessica Briscoe. We’re going to be talking about what is a migraine and the four stages of migraine.

Dr Jessica Briscoe [00:00:43] Absolutely. So what is a migraine? Essentially, without going into too much detail, we know it’s a genetic condition. That means that it runs in families. So if you know someone in your family that’s got migraine, you are very, very likely to suffer with it, too.

Dr Katy Munro [00:00:59] Yeah, that’s a double whammy if both your parents have it the risk is much higher.

Dr Jessica Briscoe [00:01:04] Absolutely.

Dr Katy Munro [00:01:05] Also, some people don’t know who in their family had migraine, and that’s because in the past it wasn’t always diagnosed or labelled. And some people who had migraine actually didn’t get it very often so just because you haven’t got a family history doesn’t mean that it’s not a genetic condition. We know there are 42 genes at least involved in changing your brain so that it is a little bit more likely to get a migraine.

Dr Jessica Briscoe [00:01:34] Yeah. And sort of what actually happens, the actual process? We don’t fully understand- we know that there’s something that gets triggered off in your midbrain, which starts all of your nerves around your head misfiring, I think is the best way to say it. It makes them a bit more sensitive. And then that starts the whole process. Which probably brings us nicely into our four stages of migraine.

Dr Katy Munro [00:01:57] Yeah. So the first one we always talk about, which people aren’t always aware of and can last for anything from one to two days before you actually get what most people think of as a migraine, which is the headache, and that’s the prodromal phase. So this is a time when patients often describe to us that they get either a lot of fatigue or they get really quite irritable. Sometimes they get yawning. Have you come across that one, Jess?

Dr Jessica Briscoe [00:02:26] Yeah, yawnings a really common one. And I think the other thing that I see is mood changes. So people getting- people say that it’s not them that notices so much it’s their loved ones. They’ll say, oh yeah, they get really low or depressed and I can tell that they’re about to get it.

Dr Katy Munro [00:02:42] Just occasionally they get a burst of energy, don’t they? And sometimes people get a craving and that can be for certain foods. And that’s where chocolate sometimes got a bad name because people get a craving for chocolate and it was a sign of them getting a migraine rather than actually being the cause of it. So the prodromal phase, lots of symptoms can happen then. It’s worth knowing about it because you might be able to work out that a migraines coming and nip it in the bud.

Dr Jessica Briscoe [00:03:09] Yeah, I mean, you’re totally right about the cravings, because I think that’s also why people think that certain smells or certain lights can be the trigger of their migraine when the whole process has actually started 12 to 24 hours beforehand. It’s often the thing that sort of tips them over the edge. But I think it’s really important to be aware of them so that they can get the treatment on board quickly.

Dr Katy Munro [00:03:31] Yeah, going back to what we were saying about what is a migraine, the genes that are in your body when you are migraine sufferer, mean that your brain is always a little bit more sensitive to things, whether or not you’ve got a migraine attack. So light, sound, movement, touch, all of those things can be a little bit of a potential trigger or you can be more irritated by them. And so watch out for those kind of things, too. So shall we talk about aura?

Dr Jessica Briscoe [00:04:01] Yeah, I think aura is the next bit which doesn’t occur in everybody. So it’s really important- because a lot of people think that- a lot of people have been quite apologetic to me, actually and say, oh I’m sorry, I don’t get an aura, does that mean I’ve not got a migraine? It’s actually far less common to have an aura. So what is aura?

Dr Katy Munro [00:04:22] Well, aura is usually a visual change that people notice, but it can be other things as well. So the visual changes could be that suddenly somebody can’t see, the centre of their vision will go or people describe that they get flashing lights or maybe a small dot expanding to the outer edges of their vision and zigzags. Zigzags are often something they describe, aren’t they?

Dr Jessica Briscoe [00:04:48] Yeah, sometimes I’ve had children describe sparkles to me and things like that, so it can actually take any form. But it’s about when it actually occurs in the attack so just before the pain phase and it doesn’t have to be visual. So there are other aura symptoms. So commonly room spinning dizziness or vertigo, the speech disturbances so not getting the right words out can be one of them. Numbness or tingling in the face and the hands or legs.

Dr Katy Munro [00:05:22] Sometimes a feeling of heaviness, just a sort of heavy feeling down the side of the body.

Dr Jessica Briscoe [00:05:28] And that’s the sort of horrible hemiplegic migraine, where you can’t move one side of the body as well.

Dr Katy Munro [00:05:34] Aura traditionally is described as coming and going within 60 minutes before the headache starts. So that aura phase is usually a fairly short phase. And as Jess was saying only about 25% of people get that. And you might have aura sometimes and not other times, and that’s migraine with and without aura and that can occur throughout people’s lives from time to time.

Dr Jessica Briscoe [00:06:00] The next phase is the pain phase. And I think that’s the thing that everyone traditionally thinks of with a migraine, that pain. This isn’t always the most troubling bit, but it can be pretty horrible for people. And it’s not just pain, actually. People can also feel incredibly sick or nauseous. They can have that sort of- they can start having some of the concentration difficulties as well. And actually, this is the point where you really need to have got painkillers on board nice and quickly.

Dr Katy Munro [00:06:32] Yes, I sort of talk about migraines being a snowball. A snowball kind of rolling and gathering momentum and getting bigger and bigger. And if you want to get rid of a snowball before it knocks you down, you need to jump on it very quickly. So the same with a migraine, really. The quicker you can get in there with medication, the better. So the headache phase is very important, but sometimes people get quite a lot of tummy symptoms as well, especially children. And we’ll do another episode about migraine in children. But just to say watch out for tummy pains in children. And the vomiting and nausea is often a common thing, and that’s caused by the stomach not emptying properly so a thing that we call gastricstasis occurs, which also reduces the absorption of the painkillers. So that headache phase is really quite important to get the medication right.

Dr Jessica Briscoe [00:07:26] And then the last bit, which a lot of people find incredibly troubling, is the post ictal phase. So that bit at the end of the migraine. And this is where people can be experiencing what is commonly described as a brain fog, where I always think of it a bit like wading through treacle with your thoughts.

Dr Katy Munro [00:07:46] Hard work to think.

Dr Jessica Briscoe [00:07:46] Yeah, everything slows down, you don’t concentrate as well. Everything just takes longer and is more difficult. And that can last for up to five days actually.

Dr Katy Munro [00:07:56] Yeah. Sometimes people describe it as, you know, the pain’s gone but they still feel as if they’ve been rolled over by a steamroller and that can go on for a long time. So the whole migraine from start to finish can last anything up to five days if you include the prodrome and right through to the end of the postdrome, feeling back to normal. And the trouble is, sometimes people are very sensitive and they’re starting to get the next one before the first one’s really gone away. So this is where we sometimes hear that people are getting really long episodes of what seems like one attack, but actually it’s probably two or three attacks rolling into each other.

Dr Jessica Briscoe [00:08:32] Yeah, and definitely not a cluster migraine.

Dr Katy Munro [00:08:36] Definitely not, definitely not. We’ll talk more about cluster headaches in another podcast. But cluster migraine is a very confusing term we discourage people from using. So, yeah, migraine, four phases, a genetic condition and unfortunately, very common.

Dr Katy Munro [00:08:51] We’re going over to Charlotte and Swati now. They spoke to some of our patients about their four stages of migraine. Here’s what they had to say.

Charlotte [00:09:01] Hi Kiera. So we’re basically talking about the four stages of migraine, so what are your stages? How do you feel before, during an attack and then actually afterwards? What does it feel like for you?

Kiera [00:09:13] Usually just before so for maybe the eight hours before I get an attack, I’ll start to feel anxious, but I won’t know why. So it’s different than other forms of anxiety that I might have. So it’s a sort of a strange feeling of anxiety. Sometimes I get nausea and often I wake up in the middle of the night with a headache.

Charlotte [00:09:36] Yes, a lot of people get that, don’t they, in the middle of the night. And what about during it? What’s it like?

Kiera [00:09:44] During it’s, you know, I get the aura, but just beforehand and then during, I’m fortunate in that I’m a migraineur who tends to be sleepy so usually I can sleep through the attack. But throbbing in the neck. So my neck is really painful and usually I’ll put an ice pack on it to help with that. And then often on the right side of my head during an attack. And then after an attack, I often will feel just like I have a terrible hangover. That’s the only thing I can really compare it to. I feel really spaced out and it’s difficult to do things.

Charlotte [00:10:22] Do you find lights and things bother you? Is it during attack and also after as well?

Kiera [00:10:27] Lights and sounds and smells. Yeah, it’s almost just like everything.

Charlotte [00:10:32] Just oversensitive to everything.

Kiera [00:10:33] Yeah. It’s like all your senses are turned off. Yeah.

Charlotte [00:10:37] Oh okay. Well it doesn’t sound very nice,.

Kiera [00:10:39] No it’s very unpleasant but I think that the National Migraine Centre is so wonderful for, you know, giving people so much information and doing this podcast. It’s great.

Charlotte [00:10:47] Yeah. No, that’s fantastic. Well, thank you very much for sharing that with us.

Kiera [00:10:50] Sure.

Swati [00:10:51] Thank you, Charlotte and thank you, Kiera. That was quite insightful. We’ve been joined by Bernie today and I will be speaking to her about her four stages of migraine. Hi Bernie. Thank you for joining us on our podcast. So today we are talking about the four stages of migraine. The first stage being the prodromal stage. Could you tell us a bit about that?

Bernie [00:11:11] Yeah, well, for me, I don’t really know for maybe the day before, I do seem to be normal, but just when I get the feeling of a little bit of pain in the side of my head, the actual migraine seems to come quite quickly after that. Sometimes I feel like my eye is kind of like squinting on one side. And I would say the feeling I get before is not really pain, just a feeling in my head, like it’s really hard to describe. So if I knew more about what was making it happen before it happened, I think it would be better.

Swati [00:11:48] Yeah. So the second phase that we talk about is aura phase. I understand that not everybody gets an aura, but do you get an aura?

Bernie [00:11:56] No, I don’t think so. I think there’s been a couple of times where I thought I kind of get a bit of a flash in my eye, but I don’t know.

Swati [00:12:04] So it could be- it’s not just the flashing lights and things, it could be a tingling in your arms. It could be things like that. A bit of vertigo. So these are also part of the aura. Do get something like that?

Bernie [00:12:13] No, not really. I had a few flashes in the eye before, but not really.

Swati [00:12:17] What about the actual attack phase? So what happens?

Bernie [00:12:21] Well, I think it comes on quite quickly for me, so it will just be a little bit of pain, then suddenly becomes a lot of pain where I feel like I have to lie down, have the lights off and then I can’t really do anything.

Swati [00:12:36] Are you sensitive to light and smell and noise?

Bernie [00:12:38] Yeah, not so much smells for me. I know lots of people get sensitive to this stuff, mainly just lights, but only when the pain’s quite bad. I feel like I need to be in the dark.

Swati [00:12:48] And how long does your attack, sort of, last usually?

Bernie [00:12:52] It really depends. Sometimes the medication seems to work pretty well within an hour or so and I can sometimes be kind of back to normal, still feeling a bit tired. But sometimes it seems like it doesn’t work and it can be a day or more. Yeah. So depends really.

Swati [00:13:13] And coming into the final phase of it. So that’s like the recovery phase, so when the attack has just gone past. How much time do you take with recovering from the attack?

Bernie [00:13:24] Yeah, I think it depends how bad the attack has been because if it’s been- sometimes when it kind of seems to go with the first dose of medication, I feel like I feel kind of fine afterwards. A bit tired and a bit spaced out, but mainly OK. But then if it’s been a bit of a longer attack, sometimes it feels like the next day or so I feel washed out and tired and yeah, out of it.

Swati [00:13:47] Well, thank you so much for sharing your experience with us.

Bernie [00:13:50] No worries. Thanks.

Swati [00:13:51] Thank you.

Dr Katy Munro [00:13:54] Thank you for joining us. Please feel free to ask us any questions you have or any topics you’d like us to discuss in future podcasts. Our email address can be found in the blurb. Please do subscribe to this podcast and share it with your friends and family. In our next episode will be discussing migraine triggers so tune in then for more information from Heads Up.

[00:14:16] You’ve been listening to the Heads Up podcast. If you want more information or have any comments email us at info@nationalmigrainecentre.org.uk. Till next time.

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