Your migraine starts before the pain does

You had chocolate on Tuesday evening and woke on Wednesday with a migraine. Obvious enough, so chocolate joins the list of things to avoid. The trouble is that the attack may well have been under way by Tuesday afternoon, and the craving was one of its first symptoms. Migraine tends to begin before the pain does, and once you know that, the whole trigger question looks different.

The stage before the headache

Clinicians call it the premonitory phase, or the prodrome. It is the opening act of a migraine attack and it usually runs for several hours, sometimes up to a day or more, before any head pain arrives. It is not aura. Aura is a separate, shorter set of neurological symptoms that only around a third of people with migraine experience, and it sits later in the sequence.

The premonitory symptoms themselves are oddly ordinary. Tiredness. Yawning far more than usual. A stiff neck. Trouble holding a thought. Mood shifting down or sideways into irritability. Cravings, thirst, needing the loo more often, finding the kitchen light unreasonably bright. On their own, nothing announces itself as a migraine, which is why it ends up as an afterthought.

There is a reason the list is these symptoms. Brain imaging points to early activity in the hypothalamus, the region that regulates appetite, thirst, sleep and alertness. So the opening signs of a neurological attack turn up looking like everyday urges.

What the diary studies found

In an electronic diary study of people who believed they had warning symptoms, the most common were feeling tired and weary, reported in 72% of attacks with warning features, difficulty concentrating in 51%, and a stiff neck in 50%. Those same participants correctly predicted a headache from 72% of the diary entries in which they logged warning symptoms.

This suggests some limitations. The study recruited people who already thought they could sense an attack coming, so the prediction rate belongs to that group rather than to everyone with migraine. What matters is that a usable warning, where one exists, is worth acting on, rather than the study statistics themselves.

What this contributes to the trigger conversation

If cravings, appetite changes and light sensitivity are early symptoms, then a good number of the things people have banned from their lives were never causes at all. The chocolate may have been the craving. The missed lunch may be the appetite drop. The bright supermarket was photophobia appearing before the pain. The Migraine Trust makes this point directly, and it truly is one of the more liberating ideas in migraine care.

This is not a licence to ignore everything. Disrupted sleep, hormonal shifts and long stretches of stress do appear to raise the odds, and keeping the basics steady is still a solid piece of migraine treatment. But you can stop auditing last night's dinner every time you wake in pain because the attack had already started.

A word about the neck, honestly

Neck pain and migraine go together. A meta-analysis of clinic-based studies found neck pain in around 77% of people with migraine, against roughly 23% of people without headache. As an osteopath I see that connection daily, and treating the neck helps a great deal of the time, but what often cannot be picked apart cleanly is if there is true neck dysfunction contributing to the attack or whether the power of touch and treatment is playing its own role.

The premonitory research adds a caveat I think is worth exploring. If a stiff neck turns up in half of attacks before the pain, then neck symptoms are sometimes part of the attack rather than the thing setting it off. Researchers are still working out how often that is the case. My own view, and it is a clinical judgement rather than settled fact, is that this is why hands-on work on the neck transforms things for some people and barely touches it for others. Which is why the useful question in clinic is not whether your neck hurts, but when it hurts relative to the headache.

Putting your early signs to work

• Name two or three, not twenty. Most people have a small, repeatable signature. Yawning and a short fuse. A heavy neck and a sweet craving. Find yours rather than ritually cataloguing every sensation.
• Log them on the same line as the attack. If you are already keeping some form of headache record, add a column for the day before. Patterns show up over a few weeks far better than memory manages.
• Act on the warning. Rest if you can, get yourself home, dim things down. If you use acute medication, it generally works best taken at the first clear sign rather than once the pain is established, though being mindful of how often you reach for it as that is the territory of medication overuse headache. If you feel you have been needing to take medication more than a couple of days each week then it is worth a conversation with your prescriber to explore preventative options.
• Bring it to your appointment. What happens in the day before an attack is diagnostic information, not just fluff. It helps separate migraine from other headache types, and most people are never asked about it because there isn't usually enough time.

If you never get a warning

Some people simply do not, or the signs are too subtle to catch, and that is not a failure of attention. If a few weeks of looking turns up nothing, look at the days afterwards instead. The postdrome, that flat, foggy day once the pain has gone, is part of the attack too, and it often says more about what migraine is costing you beyond the pain and symptoms of the acute attack than the headache hours alone.

If your headaches are frequent or hard to make sense of, a full assessment can help you understand what is driving them and what to do next. You are welcome to book an appointment or get in touch.

• Giffin NJ, Ruggiero L, Lipton RB, et al. Premonitory symptoms in migraine: an electronic diary study. Neurology 2003;60(6):935-940.
• The Migraine Trust. Prodrome: spotting the first signs of a migraine attack. migrainetrust.org
• The Migraine Trust. Triggers and premonitory symptoms, which come first? migrainetrust.org
• The Migraine Trust. Stages of a migraine attack. migrainetrust.org
• Al-Khazali HM, Younis S, Al-Sayegh Z, et al. Prevalence of neck pain in migraine: a systematic review and meta-analysis. Cephalalgia 2022;42(7):663-673.
• National Institute for Health and Care Excellence (NICE). Clinical Knowledge Summaries: Migraine. cks.nice.org.uk
• International Classification of Headache Disorders, 3rd edition (ICHD-3). ichd-3.org

This article is general information, not a diagnosis or a substitute for individual medical advice.