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Subdued 11
Depressed 6
Bad or irritable 5
Introverted 3
Relieved or happy 5
Euphoric 1
Concentration impaired 26
Attention span reduced 22
Physical energy reduced 29
Tired 27
Yawning excessively 13
Limbs tired or aching 5
Weak 5
Clumsy 5
Head pain remaining slightly 14
Awareness 2
Only on movement 3
Head tenderness
Above or around one or both eyes 5
Forehead 6
Temple (unilateral) 4
Whole head 1
Face stiff 1
Face tender 1
Tender 8
Stiff 4
Ache 2
Photophobia 5
Focusing difficulty 3
Everything very bright 2
Tired 2
Slurred 4
Dysphasic 3
Fluid balance
Drinking more 6
Thirsty 8
Increased micturition 7
Less urinary output 2
More active 6
Less active 3
Other symptoms
Slower movements3
Poor coordination and accident prone
Impaired taste 3
Sensual 2
Hyperacusis 2
Smell distorted 1
Nasal stuffiness 1
Nightmares 1

mise à jour du
18 juillet 2002
Migraine postdromes: symptoms after attacks
Blau JN
City of London Migraine Clinic, London
Jacome D Compulsive yawning as migraine premonitory symptom.
Jacome D Primary yawning headache


Physical and mental tiredness commonly follow migraine attacks. Patients rarely mention such symptoms spontaneously although when asked directly, often say they feel drained, exhausted, washed-out or fragile. This aftermath of the main migraine episode is neglected in the migraine literature, although Selby, a notable exception, regarded it as characteristic of the condition.

Because this postdromal phase has not been studied prospectively, patients were invited to record their symptoms on the day they occurred to determine their range, quality and duration.

yawning - migraine

Patients and method : Migraineurs with aura (classical migraine) or without aura (common migraine) and no other headaches, were asked to complete a one-page questionnaire on the day after the next migraine attack describing their symptoms (quality and duration) experienced after the headache had disappeared. Space was also provided for replies to specific questions about mood change, concentration, attention span, eyesight, speech, general physical energy, limb symptoms, fluid balance, bowel action, yawning, tiredness, any remaining head pain, head tenderness, effect of head movement, activities that could not be undertaken, and any other symptoms. Duration of the antecedent migraine attack, extra time spent in bed, meals missed and medication taken were also requested.

Results : Forty patients (female 31 and male 9) aged 25-66 (mean 39) years with classical (11) or common (29) migraine were studied. Migraine headaches lasted 5-72 (mean 23) h, during which time 25 of the 40 patients stayed in bed for 1-16 (mean 11) h longer than usual. The number of missed meals were 1 (13), 2 (5), 3 (4), 4 (3), 6 (1) (figures in brackets refer to the number of subjects); six subjects took smaller meals and eight ate normally. Medication taken included paracetamol with or without anti-nauseant (22), aspirin with or without anti-nauseant (7), ergotamine (3), indomethacin (3), ibuprofen (1), none (4).

After the headache had ceased, symptoms persisted for a further 2-72 (mean 18) h-most frequently "the whole of the next day". Spontaneous descriptions included feeling weary, weak, unable to summon-up energy, exhausted, tired, listless, lethargic, fatigued (yawning), washed-out, fragile, delicate, can't be bothered, everything an effort, wooly headed, not thinking clearly, confused, like a hangover; a few used more graphic terms-"a wet rag" or "like a rag doll". Euphoria and relief were also mentioned. All symptoms, spontaneous descriptions and those elicited on specific enquiry in the questionnaire, are listed in the Table.During the postdromal phase, reduced activities were physical exertion (11), bending down (2), turning head (2), sport (2), walking (2), driving (2), slower in all actions (3), unable to read (3) and impaired fine coordination (1); 12 were unrestricted in their usual daily activities.

Discussion : Symptoms after the headaches have ceased were briefly mentioned but dismissed as rare by Wolff. However, Selby called this phase "the third act in the drama" of migraine episodes, appreciating its significance as being an integral part of the condition. The neglect of postdromes in the migraine literature is surprising in view of the frequency and duration of these symptoms-47 of 50 patients in a retrospective study, and contrasts with the attention given to the aura that only affects 10-15% of migraineurs.

Eliciting the presence of postdromes can assist in diagnosing common migraine because the only other episodic headache in which symptoms persist after the painful episode is cluster headache where tenderness of the ipsilateral temple or around the affected eye can remain for several hours. But there is no difficulty in differentiating migraine from cluster headache. Asking further about postdromes aids rapport: patients often seem surprised and grateful when questioned about these symptoms, because no one has previously mentioned them.

The difficulty in determining attack duration becomes apparent from this study: patients may include or omit postdromes when estimating the length of attacks. Further, measuring attacks by hours of headache, used in a "migraine score" is open to error of patient interpretation because mild residual pain, head awareness and tenderness, or pain on head movement, may be included or omitted.

Postdromes could arise from the slow decline of the migraine process, being the converse of prodromal s~mptoms at the onset of attacks and giving symmetry to the whole episode. However, postdromal symptoms could be due to the paine experienced during the central episode, analgesics, anti-nauseants or other medication, lack of food intake, extra time spent in bed, or a combination of some or all of these factors. But simple analgesics do not have such prolonged effects, not all patients remained in bed during their attacks, and not all patients missed meals during the headache phase (see results).

Hence it is argued that at least some symptoms arise from the devolution of the primary migraine process. This notion gains some support from recent experimental observations: transient asymmetrical visual evoked potentials were recorded sequentially in three patients for 1-3 days after classical migraine attacks. In spite of the small numbers, the results were impressive because the abnormalities gradually diminished over several days after migraine episodes before the recordings returned to normal values. These observations were considered by the investigators to reflect increased functional lability of the occipital cortex, rather than structural lesions.

The observations reported here provide a pilot study of the range of symptoms affecting patients at the end of migraine attacks. The results need confirmation in a prospective study including a control group of headache patients who do not have postulated central nervous system involvement, e.g. cluster and tension headache, and even other forms of severe visceral pain, in order to determine whether postdromal migraine symptoms are specific to the central nervous system. However, the quality and breadth of postdromal symptoms suggest involvement of the whole brain, more markedly of the frontal lobes and the hypothalamus-areas implicated by prodromes. Perhaps the same symptoms are present during the intervening headache phase, when patients are tired, yawn, ex i it brain irritability (photo, phono and osmophobia), some are dysphasic and many cannot concentrate. Although severe headache could be responsible, a continuum of symptoms throughout the whole attack is possible, and therefore more detailed study of patients during attacks is indicated, in spite of obvious difficulties.

Conclusions : Postdromal symptoms after the headache phase are common, and may help diagnosing migraine, especially when there is no aura. Their elicitation helps patients gain confidence in their physician's understanding of the condition. The symptoms raise further questions about the underlying migraine process which affects the whole brain, possibly by slow neurotransmîtters or perhaps by neural metabolic disturbances.


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