Types of migraine
Migraine is a neurological disorder
The headache pain is often moderate to severe in intensity. There is a genetic component to migraine and the disease often runs in families.
There are many different types of migraine, each with distinct features. Diagnosis and proper classification should be made by a healthcare professional. Migraine can be classified based on frequency of headache (e.g. episodic or chronic), by symptoms (e.g. aura, vestibular migraine, etc) or by other related features (e.g. menstrual migraine, which is usually migraine without aura but occurring around the time of the period).
When describing migraine types, health professionals usually include both the frequency (episodic or chronic) and symptom type (e.g. migraine with aura).
Migraine with aura
Migraine with aura (sometimes known as classic migraine) occurs in up to 30% of people with migraine.
This type of migraine is characterised by a visual or sensory aura before or during the headache phase. In migraine with aura, four phases of migraine occur – the prodromal phase, the aura, the headache phase and the post-dromal or recovery phase.
Auras typically involve visual disturbances, such as seeing flashing lights, zigzag lines, shimmering spots, blind spots or loss of vision. Sensory auras can involve tingling sensations or numbness in the face or hands. Speech and language can also be affected.
Auras usually last for about 20–60 minutes before resolving. Sometimes an aura can occur without a headache, often known as silent migraine.
Migraine without aura
This is the most common type of migraine. It’s a misconception that migraine can only be diagnosed if you experience an aura. Between 70–80% of migraine attacks don’t include an aura.
The defining feature of migraine without aura is that the sensory disturbances which occur in the aura phase, before or during the headache, don’t occur. Migraine without aura has three phases – the prodromal phase, headache phase and post-dromal or recovery phase.
Vestibular migraine
Vestibular migraine is characterised by episodes of vertigo or dizziness, often accompanied by one or more migraine symptoms such as headache, sensitivity to light or sound and aura. Headache is not always a feature of these attacks.
The dizziness during an attack can last for minutes to 72 hours and may be severe.
Abdominal migraine
Abdominal migraine is a type of migraine that usually affects children, though can affect some adults. Abdominal migraine often presents as recurrent episodes of abdominal pain without an obvious gastrointestinal cause. Moderate to severe abdominal pain may last between 2–72 hours. Children may also feel sick or vomit. Usually they feel well between attacks.
Often there is a family history of migraine due to the migraine being highly genetic.
Abdominal migraine may be triggered by factors such as lack of sleep, stress and hormonal changes.
Find out more about abdominal migraine below.
Hemiplegic migraine
Hemiplegic migraine is a rare type of migraine. During an attack, temporary paralysis or weakness (hemiplegia) may occur on one side of the body. Other symptoms may include visual disturbances, difficulty speaking and confusion.
Dizziness or vertigo, ringing in the ears and confusion are also symptoms associated with hemiplegic migraine.
Hemiplegic migraine symptoms can mimic the signs of a stroke, and weakness can last from one hour to a few days. Sometimes, but not always, a headache follows.
It’s essential to seek immediate medical attention if you experience hemiplegic migraine symptoms, as they can mimic signs of stroke.
There are two types of hemiplegic migraine – familial hemiplegic migraine (FHM) and sporadic hemiplegic migraine (SHM). FHM runs in families; SHM is the diagnosis given when there is no known familial link.
Migraine with brainstem aura
This is a rare type of migraine with aura, where aura symptoms include vertigo, ringing in the ears, double vision, difficulty speaking and controlling muscle movements, and even loss of consciousness.
These symptoms can also occur with stroke and need immediate emergency assessment. The use of triptans to treat migraine with brainstem aura isn’t recommended.
Menstrual migraine
Migraine attacks that are closely related to a period or menstrual cycle are called menstrual migraine. These migraine attacks occur in the two days leading up to the menstrual bleeding to three days from when the bleeding starts.
Menstrual migraine attacks are often more severe and prolonged than non-menstrual attacks, meaning that acute treatment usually needs to be repeated for several days, as symptoms recur.
Menstrual migraine is caused by hormonal changes that occur around the time of a woman’s period. Learn more about menstrual migraine below.
Episodic versus chronic migraine
From the International Headache Society, people with migraine who have 14 or fewer headache days a month are said to have “episodic” migraine.
People with 15 or more headache days a month, with at least eight of these being headaches that are typical of migraine, are classed as having “chronic migraine”. Chronic migraine is only diagnosed when this high frequency of headache occurs for more than three months.
Chronic migraine usually develops from episodic migraine, with around 3% of people transitioning from episodic to chronic migraine per year. Risk factors for developing chronic migraine include ineffective treatment of migraine attacks, overuse of acute medications, anxiety or depression, obesity and stressful life events. People with chronic migraine can also revert back to episodic migraine, especially with effective treatment.
High frequency episodic migraine
Episodic migraine can also be classed into different types, from low frequency (0–3 headache days a month), moderate frequency (4–7 headache days a month) and high frequency (8–14 headache days a month).
The exact threshold for what constitutes “high frequency” can vary among medical professionals and organisations, but it generally involves experiencing a high number of migraine attacks over several months or a year.
High-frequency episodic migraine can cause a high level of disability. From a large US population study of people with migraine (including over 21,000 subjects), 58% of people with migraine had low-frequency episodic migraine, 19% had moderate-frequency episodic migraine, 11% had high-frequency episodic migraine and 12% had chronic migraine.
Half of those with high-frequency episodic migraine and two-thirds of those with chronic migraine reported severe migraine-related disability, compared to 10% of those with low-frequency episodic migraine.
Chronic migraine
Chronic migraine is one of the most severe and debilitating forms of migraine. Not surprisingly, disability from chronic migraine increases with the number of headache days per month. This type of migraine can significantly impact a person’s daily life, especially employment, and may require specialised treatment.
We don’t know exactly how many people have chronic migraine in NZ, as this has never been measured. From international research, it’s estimated that 7–12% of people with migraine have chronic migraine. This would equate to between 53,000–90,000 people in NZ (based on estimate of 753,000 people with migraine from 2021 Global Burden of Disease study). Other studies estimate that 1–2% of the whole population have chronic migraine, which would mean that between 52,000–104,000 people in NZ have chronic migraine (based on 2023 Census estimates).
Acute medication overuse is common in chronic migraine, where medications used to treat migraine attacks are taken for more than 10–15 days a month over a period of several months. In people with migraine disease, this type of medication use can cause headache to develop, called medication-overuse or medication-adaptation headache, which can co-exist with chronic migraine.
Withdrawal of acute medication and treatment of medication-adaptation headache can revert chronic migraine to episodic migraine in as many as 50% of people.
