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.
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.
References
