Clinical Features

What are the symptoms?

The foremost symptom is the typical headache that occurs in attacks or episodes. The headache can sometimes be mild but more commonly is moderate or severe. It is usually described as ‘throbbing’ or ‘pulsating’ along one side of the head and is often accompanied by nausea, vomiting, and extreme sensitivity to light or noise.

The patient may feel a strong desire to lie down in a darkened room and also have other associated symptoms such as neck stiffness, tingling in the limbs and difficulty in speaking. Indigestion and diarrhoea can occur in some patients and in rare cases paralysis and loss of consciousness has been reported.

The attack can last from 4-72 hours and usually resolves by gradually fading away. In some cases the attack ends suddenly after an episode of vomiting. The attack is often followed by a period of exhaustion or weakness. Most people with migraine would have several attacks per year.

There are two recognisable types of presentation. ‘Common’ migraine (or migraine without aura) occurs in about three quarters of the people who get migraine. The other quarter shows ‘classic migraine’ (migraine with aura).

In ‘common’ migraine the attack starts with the typical headache with no apparent warning.

In ‘classic migraine’ the attack is preceded by warning symptoms (aura) such as vague changes in mood, low energy levels, and feelings or hunger, thirst. This stage may be followed by neurological aura with visual symptoms of flashing lights, blind spots or zigzag lines before the eyes. In some cases there may be symptoms such as tingling around the mouth, difficulty speaking or a feeling of weakness in a limb.

The aura can last up to half an hour and is then usually superseded by the onset of headache and other symptoms. Some people, usually older sufferers, may experience the aura without the subsequent headache.

Migraine can present atypically with transient diplopia (double vision), changes to the retina of the eye or transient mild paralysis of one limb accompanying the headache. These features usually resolve fully at the end of the attack. Some individuals may have atypical forms where headache is minimal but nausea and abdominal pain predominate.

What are the physical signs?

There are no physical signs that are typical of migraine. Physical examination is of value only for eliminating other possible causes of the symptoms.