Physician-authored summaries and commentary on the most important medical research, provided by the NEJM Group, a division of the Massachusetts Medical Society.
© Massachusetts Medical SocietyMay 2025
Common prodromal symptoms include light or sound sensitivity, fatigue, neck pain and difficulty thinking or concentrating.
Some patients with migraine experience transient focal neurological symptoms (the ‘aura’) just before or accompanying the onset of headache. However, primary care clinicians might not be familiar with a nonaura ‘prodrome’ that is sometimes the earliest phase of a migraine. In this report, researchers describe prodromal symptoms in about 900 patients with frequent migraine who were aware of prodromes that usually preceded (by one to six hours) a migraine headache. Participants kept symptom diaries for 60 days as part of a previously published, industry sponsored trial in which the CGRP antagonist ubrogepant – administered at onset of the prodrome – improved migraine outcomes compared with placebo (NEJM JW Neurol Dec 15 2023 and Lancet 2023; 402: 2307-2316).
The most common prodromal symptoms were light sensitivity (in 57% of prodromes), fatigue (50%), neck pain (42%), sound sensitivity (34%), difficulty thinking or concentrating (30%), dizziness (28%), irritability (26%) and nausea (23%). Half the participants recorded five or more different prodromal symptoms, and patterns of symptoms tended to be consistent. In 5% of cases, headache onset was more than six hours after onset of prodromal symptoms.
Comment: This report enhances our understanding of the earliest phase of a migraine attack. The question is whether to recommend abortive treatment as early as the prodrome in patients who can reliably predict that headache will follow. Although we need more data on the effectiveness of abortive treatment during the prodrome, some neurologists are already doing this in selected cases using acute migraine treatments such as CGRP antagonists and triptans.
Allan S. Brett, MD, Clinical Professor of Medicine, University of Colorado School of Medicine, Aurora, USA.
Schwedt TJ, et al. Characterizing prodrome (premonitory phase) in migraine: results from the PRODROME trial screening period. Neurol Clin Pract 2025 Feb; 15: e200359.
This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Neurology.