The Migraine Patient Journey: Episodic Migraine and CGRP Inhibitors - Episode 4

Migraine: Left Versus Right-Sided Attacks and Postdrome Symptoms

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Neurologist Jessica Ailani, MD, explains what is understood about the location of migraine attacks and symptoms in patients and describes the types of symptoms patients may experience during a “headache hangover."

Philippa Cheetham, MD: Dr Ailani, we are hearing about these initial warning signs and sometimes there can be very obvious ways to act quickly at the onset of a migraine attack, ways to try to abort an attack. But sometimes that does not make any difference. I have only ever experienced migraines on the left side of my face, my head, my arm, and my leg. They are never on the right side, and there are times when I do not even have a headache, but I am aware that the left side of my body feels different to the right side. It is almost like the left side is somehow left oversensitized after a bad migraine, where I feel as if it is just bubbling under the surface. It may come back after a few days just by eating too many refined sugars or not enough sleep or the wrong environment. 

Why is it that so many patients with migraine say migraine attacks always affect the left or the right? Why is it that there is this hangover effect, where even when the migraine is gone, you are still aware of a difference on the right vs the left side of your body?

Jessica Ailani, MD: I am going to address the second question first; it is actually a little easier to answer than the first question. What you guys are both talking about is what we call a postdrome; the last part of a migraine attack is the “headache hangover,” as my patients so aptly put it. The migraine is gone, but there is this lingering fog. You are not really yourself; you do not feel good. Maybe your stomach is moving again, but your mind is not up to speed and you might still have a lingering mild headache. Maybe, as you mentioned, any kind of abnormal movement or doing things like going to the grocery store can trigger it off again. 

We look at this, and we see that the brain is starting to settle back into a normal pattern. But it is not quite at the baseline, it is not quite normal, so it is easy to trigger it back into a migraine attack again. We look at it this in the same way that we do a fireplace that is on. You put water on it and got the fire down a bit, but it is still kindling and you are not supposed to walk away from it. That is really what a postdrome is. There is still a little bit of kindling going on where the brain is still active.

This idea that part of your body feels abnormal is something we sometimes describe as allodynia, where normal sensation is painful or part of yourself does not feel right, and you can see this lingering after a migraine attack or even during a very severe migraine attack. This is a sign again of that kindling—the brain is on fire and it needs to be calmed down.

I will sometimes tell my patients that, when they notice this, it is especially important the day after an attack, especially a very severe attack, that you keep hydrated, you limit your activities, you do not overdo it, you do not exercise that day, you do not try to run that 5K, you do not put all the lights on in the office, go to the grocery store, and do the laundry. Make up the day that you missed, but take it easy. Then we investigate how we can treat that next attack differently, so you do not land in that situation again, where the postdrome is so bad. You are ready to go with the next cycle.

As to why it always favors 1 side, I think of it like this: If it is easier to ride a bike 1 way, you are always going to do it 1 way. We form a racetrack on 1 pathway. That 1 nerve gets overactivated, and it becomes very easy to constantly activate that 1 peripheral nerve, so it keeps at it and it is very easy to target that 1 side again.

Philippa Cheetham, MD: Do you believe that the pathophysiology is an abnormal function of nerves, or do you think that some patients with migraine may potentially have abnormal blood flows? We know the brain is fed by this circle of Willis [cerebral arterial circle]—the 360-degree supposedly intact circle of blood vessels that link in a halo around the body—and that there are differences in anatomy across individuals. Do you think there is any evidence that differences in anatomy of blood flow to the brain may predispose 1 person more than the other to migraines?

Jessica Ailani, MD: It is unlikely that different anatomy will predispose you to migraine attacks, unless you have a vascular malformation like an arterial malformation or an aneurysm of some sort. It would have to be rather large and in just the right location to trigger a migraine. We instead have come to realize that migraine is more of a peripheral and central nervous system problem. There is a misfiring between the nerves on the outside and how they are communicating with the brain; they turn on parts of the brain that go haywire. They are turned on when they are not supposed to turn on, so everything is brighter, everything is louder, everything smells stronger. My migraine patients can tell you what someone ate for lunch at dinnertime. They can hear the sirens and the fire 3 streets down. They are the first 1 out of the house when there is really a problem.

In some ways, when we think of migraine, it is probably what protected so many people and got us into this generation. Migraine attacks may have had some protective mechanism back in the caveman days where people were hunters and gatherers. The migraine patients knew not to eat the wrong food because it smelled funny and stayed in the back on a rainy day, so they did not get killed in the thunderstorms and lightning storms because their brain was protecting them. Unfortunately, it does not have that protective mechanism anymore, but it speaks to how the brain of someone with migraine attacks is overactive and turns on all those signals. 

We have come to realize it is this trigeminal nerve in the peripheral system that then activates the hypothalamus, the thalamus, and the trigeminal nucleus caudalis. It communicates back with the frontal lobe and the temporal lobe, and all this starts to misfire and become overactive. This causes oversensitization of the brain, which then causes oversensitization of the nerve, which then causes oversensitization of the brain. What we are trying to do when we treat this is break that cycle and calm both of these processes down.

Philippa Cheetham, MD: Thank you for watching Neurology Live® Cure Connections®. If you enjoyed the program, please subscribe to our e-newsletter to receive upcoming programs and other great content right in your in-box. Thank you so much.

Transcript Edited for Clarity