Migraine attacks come in phases for many people. They start with a constellation of possible symptoms, from fatigue, neck stiffness, yawning, sensitivity to light, sound, touch and smell, food cravings, mood changes and blurred vision. These can last for an hour or two or even a few days.
Then, in 20–30% of people with migraine, an aura can occur, most commonly causing visual disturbances, such as flashing lights, black spots and loss of vision, and strange shapes and colours. After this, comes the headache phase that most people associate with a migraine attack, often on one side of the head, throbbing or pulsating and accompanied by nausea, vomiting and intolerance of light and sound, which can also last for a few hours to a few days.
Finally, once the headache resolves, there can be another one or two days of persisting lethargy, brain fog and any combination of symptoms from the other phases of an attack. Some people experience relief and euphoria in this phase.
All this to say, that migraine symptoms can persist well beyond the bounds of the typical headache. We often say a migraine attack is “not just a headache” – and this means not only that migraine attacks encompass more symptoms than head pain but that these symptoms can encompass a much greater time period than the head pain.
For people who have frequent migraine attacks, these phases can bleed into each other, until it's difficult to know when one attack has ended and another one starts. These persistent non-headache symptoms can have a significant impact on quality of life, emotional well-being, work and relationships.
We often count headache days to assess the chronicity of migraine – if you have headache on 15 or more days a month, that is classified as “chronic migraine”. Another way to assess how much migraine is impacting on your life is to ask about “crystal-clear days” – the number of days a month that you have had none of the non-headache migraine symptoms.
The answer may be surprising. Many people with chronic migraine might not remember their last crystal-clear day. People with frequent migraine attacks learn not to take their crystal-clear days for granted, knowing how much a crystal-clear day is worth. This is a day when you have energy, you don’t feel sick, your gastrointestinal system is functional, you can think and plan and analyse and critique, you don’t have to wear sunglasses or earbuds to block out light and sound, you can exercise and go to work and see friends and do tasks and everything is easy. These precious crystal-clear days are a gift that people without migraine don’t even realise they have.
We need to pay more attention to the non-headache symptoms of migraine and the number of unclear days that people with migraine experience. Currently, we know little about the effect of migraine treatments on non-headache symptoms, because clinical trials on these medications only measure the impact on headache frequency, severity and duration. This means that we know little about how to treat and manage unclear days, even though we know that the burden and cost of these days is significant.
One thing all of us with migraine can do is to recognise and talk about these non-headache symptoms, to make health professionals and people in our lives realise that there is more to a migraine attack than “just a headache” in so many ways.
- Hubig, L.T., Smith, T., Williams, E. et al. Measuring interictal burden among people affected by migraine: a descriptive survey study. J Headache Pain. 2022;23.
- Lo, S.H., Gallop, K., Smith, T. et al. Real-World experience of interictal burden and treatment in migraine: a qualitative interview study. J Headache Pain. 2022;23(65).
- Lee, W, Cho, S-J, Hwang, H, et al. Crystal-clear days and unclear days in migraine: A population-based study. Headache. 2022; 62: 818- 827.
- Carvalho, I. Fernandes, C.S. Damas, D.D., et al. The migraine postdrome: Clinical characterization, influence of abortive treatment and impact in the quality of life. Clinical Neurology and Neurosurgery. 2022; 221(107408)
- Vincent, M. Viktrup, L. Nicholson, RA., et al. The not so hidden impact of interictal burden in migraine: A narrative review. Frontiers in Neurology. 2022;13.