Premonitory-like symptomatology in migraine

I t has been historically accepted that migraine involves symptomatology outside of head pain. These symptoms can be as equally disabling as the pain, and can include tiredness, concentration impairment, memory impairment and mood change. The symptoms may start before the onset of pain and can persist throughout the headache phase, and even after effective headache treatment into the postdrome. Despite knowledge of these symptoms, their neurobiologic basis and relationship to migraine pain is poorly understood. The fact that these symptoms start early, up to hours to days before the onset of headache, and are so symptomatically heterogeneous, suggests that the neurobiology of migraine extends beyond conventionally accepted anatomical pain areas within the brain – what has been known as the pain matrix or network. In a research area where no effective acute abortive drugs have gained a license for migraine since the triptans (serotonin 5-HT 1B/1D receptor agonists), in the 1990s, further understanding of such symptomatology will allow therapeutic advances for treatments that may work before the onset of migraine pain and thus prevent it. This review will outline our current understanding about the phenotype and neurobiology of the premonitory (prodromal) symptoms, which for the purpose of this review will be called ‘premonitory-like’, given they can start before or during pain. Symptoms starting after pain resolution (postdromal symptoms) will not be covered here.