9 Clinical Signs and Symptoms of Migraine Prodrome: At-a-Glance for Primary Care
The premonitory constellation of neurologic, autonomic, and behavioral symptoms is increasingly understood as the earliest manifestation of migraine pathophysiology.
Migraine disorder: 12% of US population experiences migraine, making it one of the most common headache disorders. The disorder has 4 distinct phases: Prodrome → Aura → Headache → Postdrome
Migraine prodrome: This is the premonitory phase preceding migraine headache and occurs between 24-48 hours before headache phase.The prodrome may last between 4 and 72 hours if untreated.
Migraine prodrome vs migraine aura
Neurologic symptoms of migraine prodrome. Visual changes: Blurred vision, difficulty focusing, and is distinct from aura, which includes flickering lights, zigzag lines, blind spots. Cognitive symptoms: Difficulty concentrating, mental fog, and restlessness.
Musculoskeletal & physical symptoms of migraine prodrome. Stiff neck, throbbing pain in posterior neck region. Note red flag: Neck stiffness + headache + fever + nausea/vomiting requires immediate evaluation for meningitis or other serious conditions.
Autonomic symptoms of migraine prodrome. Temperature dysregulation including feeling cold, shivering and excessive sweating. Fluid imbalance, including frequent urination, excessive thirst, systemic edema.
Behavioral and mood changes of migraine prodrome. Depression, anxiety, and irritability; euphoria (in some people. Difficulty falling asleep, waking unrefreshed. Sleep disruption is increasingly recognized as both a symptom and trigger of migraine.
Most common prodromal symptoms. Half the 900 participants in a recent study of the spectrum of prodromal symptoms* recorded ≥5 different symptoms, and the patterns of symptoms reported tended to be consistent. In 5% of cases, headache onset was >6 hours after onset of prodromal symptoms.
*Schwedt et al. Neurol Clin Pract. 2025;15(1). doi:10.1212/CPJ.0000000000200359
Acute migraine management strategies. Pharmacologic: triptans (sumatriptan, rizatriptan, etc.), gepants (ubrogepant [Ubrelvy] and rimegepant [Nurtec ODT]), ergotamine derivatives. Nonpharmacologic: cold compress to forehead, rest in dark, quiet environment, adequate hydration, trigger avoidance (light, sound, odor)
Migraine prevention, patient education. Lifestyle modification, regular sleep schedule, adequate rest, regular meal timing, limited caffeine intake, alcohol and tobacco avoidance, regular exercise program, stress management techniques, Keep migraine diary to track triggers, recognize/treat prodrome early.
Migraine prodrome clinical pearls. "Triggers" may be prodrome symptoms, Sleep is bidirectional, early intervention is key, comprehensive assessment should include screening for psychiatric comorbidities, patient empowerment improves outcomes.
Migraine remains one of the most prevalent and debilitating neurological disorders globally, affecting approximately 15% of the worldwide population and roughly 1 in 7 Americans annually.1 Despite its high prevalence, the prodromal phase of migraine, occurring in approximately 60% of migraineurs,2 remains underrecognized in clinical practice, representing a critical missed opportunity for therapeutic intervention.3
The prodrome, or premonitory phase, manifests 24 to 48 hours before the headache phase and can persist for 4 to 72 hours if untreated.3 This phase is characterized by a constellation of neurological, autonomic, and behavioral symptoms that are increasingly understood to represent the earliest manifestations of migraine pathophysiology rather than mere precipitating factors.4 Recent evidence has challenged traditional concepts of migraine "triggers," suggesting that symptoms such as food cravings, mood alterations, and sleep disturbances may be early migraine phenomena rather than causative agents.1
The short slide show above summarizes the primary signs and symptoms comprising the migraine prodrome, with the caveat that not all people who experience the premonitory phase report all or all of the same symptoms.
References
Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: figures and trends from government health studies. Headache. 2018;58(4):496-505. doi: 10.1111/head.13281
Rossi P, Ambrosini A, Buzzi MG. Prodromes and predictors of migraine attack. Funct Neurol. 2005 Oct-Dec;20(4):185-191.
Gao L, Zhao F, Tu Y, Liu K. The prodrome of migraine: mechanistic insights and emerging therapeutic strategies. Front Neurol. 2024 Nov 29;15:1496401. doi: 10.3389/fneur.2024.1496401
Schwedt TJ, Lipton RB, Goadsby PJ, et al. Characterizing prodrome (premonitory phase) in migraine: results from the PRODROME trial screening period. Neurol Clin Pract. 2025;15(1). doi:10.1212/CPJ.0000000000200359
