Migraine headaches don't work around your schedule — leading folks to miss everything from work, school or important moments with family and friends. Unfortunately, many who experience migraines can't plan for when they'll be indisposed by an attack, let alone how long it will last.
We spoke with a Houston Methodist headache specialist about how long a migraine can last and what most people can expect from these terribly painful and often inconvenient headaches.
The four stages of a migraine
To understand how long a migraine can last, it's important to know the four stages. Each stage has its own duration, which adds up to the overall timeline of a migraine.
"Classically, a migraine is supposed to be comprised of a prodrome, followed by an aura, the migraine headache itself and then postdrome," says Dr. Stacy Smith, a neurologist and headache medicine specialist at Houston Methodist. "Now, in real life, patients can have a wide variety of experiences. Migraine does not always follow the pattern you expect. It can do whatever it wants."
Dr. Smith says that while individuals will notice patterns in their symptoms, their migraines won't always follow the same script in terms of logically following the four stages or even including all four stages.
Prodrome
The first stage of a migraine is the prodrome, also sometimes called the preheadache or premonitory phase. The prodrome is a constellation of symptoms that warns a migraine is on the horizon.
"Prodrome is a set of nonspecific symptoms that can start anywhere from a few hours to a few days before the actual headache," Dr. Smith says. "Some patients pick up on that, but otherwise, it's not nearly as specific as some of the symptoms around the headache, so many people don't recognize it. It's harder to know if everyone experiences prodrome or not because some people may just not be in tune with their body."
The symptoms can be vague and will vary from person to person, from migraine to migraine. Someone can experience any of the following:
- Fatigue
- Cravings for foods high in salt, fat or sugar
- Mood changes, including irritability, sadness
- Muscle stiffness, often in the neck
- Nausea
- Increased urination
- Issues with concentrating, reading or speaking
- Sensitivity to light and/or sound
- Trouble sleeping
- Yawning
Aura
About a third of all people who experience migraines experience sensory disturbances before their headache, called an aura.
"The aura stage usually lasts five to 60 minutes before the headache, and it most commonly consists of visual changes," Dr. Smith says. "Patients usually describe zagging, colorful lights like a kaleidoscope. Classically, it starts as a little dot and becomes a 'C' shape, and it grows up and out of the visual field."
Dr. Smith says that aura occurs in both eyes simultaneously, and even if a person closes or moves their eyes, they still see it. This is because auras originate in the brain due to waves of abnormal neuron firing.
"You can't escape the aura," Dr. Smith says. "There may be some area right next to the shimmery spot in their vision where they can't see. You can get these positive phenomena where they see bright flashing lights, zig-zag lines or colored spots, and negative phenomena, which is the loss of vision."
Dr. Smith says that most patients who experience aura report it lasting for about 20 minutes, with the headache portion immediately following — but there are outliers.
"The aura can happen before, during or after the headache," Dr. Smith says. "And the headache may not have all the typical migraine features."
Headache
The headache stage is what most people think of when they think of migraine. It is often described as someone drilling into or taking an ice pick to their head.
"The headache is usually moderate to severe in intensity with a throbbing or pulsating quality that gets worse with physical activity," Dr. Smith says. "Generally, it occurs on one side of the head and is associated with light sensitivity, noise sensitivity, nausea and vomiting."
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Dr. Smith says that people's experiences with aura and migraine may not follow the textbook format. Someone could have an aura during or after the headache instead of it being the harbinger. She also emphasizes that for some, the aura can be the worst part of the experience because the headache is milder.
Postdrome
Postdrome is often compared to a bad hangover. About 80% of people who get migraines will have prodrome but may not have it with every migraine.
"The postdrome, like the prodrome, are nonspecific feelings," Dr. Smith says. "There can be fatigue and some persistent nausea. A lot of people just feel wiped out."
People also report body aches, dizziness, difficulty concentrating, feeling sad or anxious, or a continued sensitivity to light.
Like a hangover after too many margaritas, people in the postdrome phase of a migraine will want to go easy on themselves. Avoiding headache triggers, staying hydrated and limiting activity can help get through this phase, which lasts anywhere from 24 to 48 hours after the headache itself concludes.
Is there a right time to treat a migraine?
If you start feeling fatigued or your eyesight is suddenly impacted, it may seem logical to take your medication to prevent a migraine, right? Dr. Smith says it isn't that cut and dry.
"Typically for acute treatment, we recommend they treat as early in the headache as possible, but at the same time, letting patients use their judgment," Dr. Smith says. "Some of that comes from the fact that the prodrome and the aura don't really respond well to acute treatments."
Many medicines used to treat migraine have been designed to treat the headache and its accompanying symptoms, such as nausea and vomiting. Additionally, some migraine therapies don't entirely end the migraine attack — so if the medication is taken too early, it will run its course, and headache symptoms will return.
"We don't want them treating so early that the medicines are wearing off, and they have to take more," Dr. Smith says. "Generally, many of these medicines are limited to one or two doses in a day. And if the half-life of the medicine is eight hours, meaning it's probably going to last about eight hours in your system, and your headaches typically last 24, some of it is being strategic with hitting it at the right point."
That being said, Dr. Smith says people with migraine may have to experiment with the timing of their acute medicines, depending on their typical headache pattern and how quickly the medicine takes effect.
"If you know that the medicine you use takes 30 minutes or more to get into your system, use your judgment," Dr. Smith says. "If you have an aura and it usually lasts 20 minutes and you know that the headache is coming because 100% of the time in your life you've gone on to have a headache with your aura, find your medicine and get it ready. Once you know that headache is coming, go ahead and take it; maybe they can be preemptive in getting on top of that pain."
Can a migraine last so long that it becomes an emergency?
Dr. Smith says having a clear plan for managing the course of your attacks is crucial since the last place anyone wants to be during an active migraine is a loud, brightly lit urgent care or emergency room. But if a headache lasts longer than three days, the attack is categorized as status migrainosus, which can lead to emergency room visits.
"A typical migraine itself is not going to have a significant, severe impact like a stroke or a heart attack that must be treated right away. That being said, the symptoms can be quite debilitating," Dr. Smith says. "Some people get intractable nausea and vomiting, and they can't keep any food or medicine down. We encourage them to use their judgment, and if they have maxed out their home therapies and feel they need something more, they may need to seek treatment at an urgent care or emergency room, where they could be given medicines to treat the headache in a non-oral route and to hydrate them."
Dr. Smith recommends reaching out to your primary care or headache specialist to see if they can send orders for medicines to an infusion center or urgent care to help end an extended attack and keep you out of a busy, congested emergency department.
"Our goal is to keep people home, if possible," Dr. Smith says. "But if they've exhausted their treatment options at home, and they don't feel like it's resolving, that is the next step."
So how long does a migraine last?
While a typical migraine runs its course anywhere from four to 72 hours, Dr. Smith underscores that there will always be variability with migraine, even for those who are attuned to their bodies and individual migraine patterns.
"There is no 'it should have resolved by now,'" Dr. Smith says. "Ideally, the symptoms are treated early, and they don't have any disability, but each attack can be different in its stages and duration."
However, Dr. Smith says that patients should seek care if an attack is distinctly different from any prior attack, particularly with new neurologic symptoms.
Since migraines can include symptoms such as vision changes, numbness, tingling, speech changes and weakness, it's important to rule out a stroke if these symptoms have never been part of your usual migraine attacks. If you're unsure, Dr. Smith says it's always better to err on the side of seeking immediate care.
"I tell patients if something is abruptly different or there's new neurologic symptoms, that may be their red flag to go seek emergency care," Dr. Smith says. "If it turns out to be a migraine, you went to the ER and you get the headache, and it's very obvious the aura is going away … but you know what? It was better to be safe than sorry."
