Migraine attacks are often preceded by
premonitory symptoms. Prevalence rates of
migraine patients reporting one or more
premonitory symptoms show considerable
variability and rates range between 12% and 79%.
Sources of variability might be differences in
study population or research design. Using a
questionnaire, we retrospectively studied the
prevalence of 12 predefined premonitory symptoms
in a clinic-based population. Of 461 migraine
patients, 374 (81%) responded. At least one
premonitory symptom was reported by 86.9% and
71.1% reported two or more. The most frequently
reported premonitory symptoms were fatigue
(46.5%), phonophobia (36.4%) and yawning
(35.8%). The mean number of premonitory symptoms
per person was 3.2 (+/- 2.5). Women reported 3.3
premonitory symptoms compared with 2.5 symptoms
in men (P = 0.01). Age, education, migraine
subtype (with or without aura) and mean attack
frequency had no effect on the mean number of
symptoms per individual. In conclusion,
premonitory symptoms are frequently reported by
migraine patients. Sensitivity and specificity
of premonitory symptoms for migraine need to be
assessed using prospective methods.
Introduction
Migraine is a severe paroxysmal
neurovascular disorder and considered a major
cause of disability by the World Health
Organization. The primary cause of a migraine
attack is unknown but probably lies within the
central nervous system. Prior to the start of
the headache phase several non-headache symptoms
(often called premonitory symptoms) are reported
by migraine patients, such as changes in mood,
behaviour and sensory perception. In a selected
population migraine patients were able to
predict an upcoming migraine attack well before
the start of the headache phase. Prevalence
rates of patients reporting one or more
premonitory symptoms range between 12% (5) and
79%. One source of variability in prevalence
rate might be differences in study population.
In population-based studies rates range from 12%
in migraine patients without aura to 18% in
migraine patients with aura, whereas in
clinic-based studies prevalence rates range from
33% to 79%. Other sources of variability might
be differences in study design, such as
preselection of patients or unclear definitions
of premonitory symptoms.
In this study we assessed the prevalence of
12 frequently reported premonitory symptoms
using a questionnaire in a large unselected
clinic-based population and only symptoms
preceding two or more out of three attacks were
considered a premonitory symptom.
Discussion
The proportion of migraine patients
reporting premonitory symptoms was high: 86.9%
of patients reported at least one symptom. This
high prevalence rate is comparable to one
previous clinic-based study, where the rate was
79% (6), but in contrast to two other studies,
where rates were about 33%. Variability in rates
might be explained by differences in study
design such as preselection of patients or
differences in symptoms that are included in the
questionnaire. Furthermore, the study of Amery
was conducted before the introduction of the IHS
migraine criteria. Another source of variability
might be the studied population. For example,
prevalence rates in population-based studies
have shown to be as low as 12%. It may be that
patients identified in a population-based
setting are not informed about premonitory
symptoms in migraine and therefore are less
aware of these symptoms. Fatigue was the most
common premonitory symptom and the order of
reported symptoms is comparable to a previous
study in a selected population. In our study the
percentage of patients presenting with aura was
high. Patients with aura are more likely to
consult a neurologist than those without aura
and this differencemight be increased due to the
fact that all patients in the Netherlands see
their general practioner first in case of
complaints. However, no significant differences
in premonitory symptoms were seen between
migraine subtypes.
Females reported more premonitory symptoms
than males. An overlap between premonitory
symptoms and premenstrual syndrome may explain
this difference. Furthermore, more females
reported craving and nausea as premonitory
symptoms compared with males. This is an
interesting finding since craving for chocolate
and sweets is more common in females than in
males. Nausea is also more frequently reported
in females than in males inacute myocardial
infarction and after anaesthesia. The
physiological basis for this gender difference
is not clear. Besides gender differences,
cooccurrence of premonitory symptoms within one
subject was studied. The strongest associations
were found between depression and symptoms such
as irritability, concentration problems and
fatigue. Cooccurrence of these mood symptoms
might not be a coincidence, since they are all
part of the DSM IV criteria for dysthymic
disorder and major depression.
There might also be an overlap between
premonitory symptoms and trigger factors in
migraine. A migraine trigger is any factor that
on exposure or withdrawal leads to the
development of a migraine attack, whereas
premonitory symptoms are a consequence of an
ongoing attack. For example, mental stress
(either the acute episode or the relief period
after an acute episode) is often considered a
trigger factor in retrospective questionnaires.
However, it is unclear whether migraine attacks
can be triggered in an experimental provocation
study. So, it could be that mental stress
triggers a migraine attack or that patients
perceive more mental stress because they are in
the premonitory phase of a migraine attack.
Future prospective diary studies or experimental
studies are needed to address this
question.
This study, as well as other retrospective
studies assessing premonitory symptoms in
migraine, has some limitations. First, the list
of possible premonitory symptoms is based on
previous studies (3, 4, 8) and may seem somewhat
arbitrary. To be complete, a study should
include a full exploration of all possible
symptoms associated with a migraine attack.
Second, non-responders may have introduced some
bias. However, the response rate was 81% and
there were no differences in age, sex or
migraine subtype between responders and
nonresponders (data not shown). Third, when
should a symptom be classified as a premonitory
symptom?
We excluded photophobia as a premonitory
symptom, but it could be argued that phonophobia
and nausea are actually part of the headache
phase and therefore not premonitory symptoms.
Furthermore, in this study we considered
symptoms as premonitory if two-thirds of attacks
were preceded by this particular symptom. In
order to assess the sensitivity and specificity
of individual premonitory symptoms for migraine
attacks, possible premonitory symptoms and
migraine attacks need preferably to be studied
prospectively (4, 16). Also, the temporal
relationship between possible premonitory
symptoms, aura and the occurrence of headache
needs to be assessed in a prospective
design.
In conclusion, premonitory symptoms
are frequently reported by migraine patients.
Sensitivity and specificity of premonitory
symptoms for migraine need to be assessed using
prospective methods.
-Quintela
E, Castillo J, Munoz P, Pascual
J.Premonitory and resolution symptoms in
migraine: a prospective study in 100 unselected
patients.Cephalalgia. 2006;26(9):1051-1060.
Migraine : il y a des
symptômes avant la crise chez plus de 80 %
des patients
La migraine s'accompagne très souvent
de symptômes autres que la
céphalée avant, pendant et
après la crise. Ceux qui
précèdent la crise et qui sont
à distinguer de l'aura elle-même,
s'il y en a une, n'ont été que peu
explorés dans les études
cliniques. Or la valeur prédictive
éventuelle de ces symptômes
pourrait avoir des implications dans la prise en
charge de la crise migraineuse.
Encore faut-il préciser la
prévalence de ce type de manifestations
« prémonitoires ». C'est ce
à quoi s'est employée une
équipe de Leiden (Pays Bas) qui a soumis
461 migraineux à un questionnaire leur
demandant s'ils éprouvaient, avant la
survenue de leur crise un ou plusieurs
symptômes parmi douze
pré-définis. Un peu plus de 80 %
(374) des patients ont répondu, ce qui a
permis de constater que 86,9 % d'entre eux
rapportaient au moins une manifestation
prémonitoire et 71,1 % deux ou plus. En
fait, le nombre moyenne de symptômes
prémonitoires par personne était
de 3,2 +/-2,5 (3,3 chez les femmes et 2,5 chez
les hommes), l'ensemble de ces chiffres
témoignant d'une prévalence
élevée.
Les symptômes les plus
fréquemment signalés
étaient la fatigue (46,5 % des sujets),
puis la phonophobie (36,4 %) et les
accès de bâillements (35,8
%). L'âge, le niveau d'éducation,
non plus que le type de migraine avec ou sans
aura n'ont semblé avoir d'influence sur
le nombre de symptômes
prémonitoires rapportés.
Ainsi une symptomatologie prodromique
(à distinguer de l'aura)
apparaît-t-elle très
fréquente chez les sujets migraineux. Une
étude plus ancienne avait montré
que les sujets présentant ces
manifestations prémonitoires
étaient capables de prédire avec
précision la survenue d'une crise de
migraine.
Il faut néanmoins attendre des
études prospectives pour établir
la spécificité et la
sensibilité de ces signes.
Il reste que sur un plan purement clinique,
il est intéressant de s'enquérir
auprès des patients de l'existence de
tels prodromes, cette donnée étant
susceptible d'influer sur la prise en charge
globale de la maladie.
