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Premonitory symptoms in migraine

An electronic diary study

From the Institute of Neurology (Drs. Giffin and Goadsby), Queen Square, London, UK; Neurosciences (Dr. Macrae, L. Ruggiero and J. Altman), GlaxoSmithKline, UK; Albert Einstein College of Medicine & Innovative Medical Research (Dr. Lipton), Towson, MD; Thomas Jefferson University (Dr. Silberstein), Philadelphia PA; and Department of Neurology (Drs. Tvedskov and Olesen), Glostrup Hospital, Copenhagen, Denmark.

Address correspondence and reprint requests to Prof. Peter J. Goadsby, Institute of Neurology, Queen Square, London WC1N 3BG, UK; e-mail: peterg{at}ion.ucl.ac.uk

Background: Migraine is frequently associated with nonheadache symptoms before, during, and after the headache. Premonitory symptoms occurring before the attack have not been rigorously studied. Should these symptoms accurately predict headache, there are considerable implications for the pathophysiology and management of migraine.

Methods: Electronic diaries were used in a 3-month multicenter study to record nonheadache symptoms before, during, and after migraine. The authors recruited subjects who reported nonheadache symptoms in at least two of three attacks that they believed predicted headache. Symptoms were entered in the diaries by patient initiation and through prompted entries at random times daily. Entries could not be altered retrospectively. Data recorded included nonheadache symptoms occurring during all three phases of the migraine, prediction of the attack from premonitory symptoms, general state of health, and action taken to prevent the headache.

Results: One hundred twenty patients were recruited: 97 provided usable data. Patients correctly predicted migraine headaches from 72% of diary entries with premonitory symptoms. A range of cognitive and physical symptoms was reported at a similar rate through all three phases of the migraine. The most common premonitory symptoms were feeling tired and weary (72% of attacks with warning features), having difficulty concentrating (51%), and a stiff neck (50%). Subjects who functioned poorly in the premonitory phase were the most likely to correctly predict headache.

Conclusions: Using an electronic diary system, the authors show that migraineurs who report premonitory symptoms can accurately predict the full-blown headache.

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