Types of Migraine

How Many Types of Migraine Are There?

A migraine is not just a bad headache. It is a complex neurological condition, with multiple subtypes, each with different symptoms, triggers and treatment approaches.

The International Headache Society identifies a range of migraine subtypes, broadly categorised into whether they arise with an aura or without. The main subtypes include:

• Chronic migraine

• Vestibular migraine

• Hemiplegic migraine

• Menstrual migraine

The International Classification of Headache Disorders (ICHD) defines and classifies all known headache disorders

Migraine With Aura

A migraine with aura is one where patients may experience neurological symptoms as part of a migraine attack. These usually occur before or during the throbbing headache.

Affecting about a third of migraine sufferers, aura symptoms develop gradually over 5 minutes and last between 5 and 60 minutes.

Symptoms of aura.

Visual aura is the most recognisable form and can vary widely. Common descriptions include:

• Scintillating scotoma - starting as small flickering lights in the centre of your vision.

• Fortification spectrum - that looks like a cracked windscreen with shimmering edges or colourful, zig/zag lines.

• Tunnel vision or blind spots

Sensory aura begins as tingling or pins and needles in the hand which spread to the face, usually only on one side of the body.

Speech/language aura, also known clinically as dysphasia, can be alarming. Symptoms may be confused with a stroke and include:

• Difficulty finding words

• Slurred or confused speech

Motor aura is linked to hemiplegic migraines. Whilst rare, patients may experience partial weakness or paralysis on one side of the body. This requires urgent medical review to rule out a stroke.

When does aura occur?

An aura gradually occurs over a period of 5 minutes and can last up to an hour. Some may experience aura throughout the attack, with others experiencing symptoms after the headache has begun.

Migraine with aura is associated with a slight increased risk of stroke, particularly in those who:

• Smoke

• Have high blood pressure

• Take the combined oral contraceptive pill

Although increased, the overall risk linked to migraine is still very low.

Migraine Without Aura

Up to 80% of migraine sufferers experience migraine without aura. This is the most common type of migraine.

These migraines consist of a moderate to severe throbbing headache with nausea and sensitivity to light, sound or smell.

Diagnostic criteria

The ICHD-3 is a classification system which provides standardised, evidence-based diagnostic criteria for all headache types.

A confirmed diagnosis of migraine includes:

Duration

• 4 to 72 hours - untreated or unsuccessfully treated

At least 2 of the following:

• Unilateral (one-sided) pain

• Pulsating/ throbbing quality

• Moderate to severe intensity

• Aggravated by, or causing you to avoid a routine physical activity

At least 1 of the following:

• Nausea and/or vomiting

• Sensitivity to light (photophobia) and sound (phonophobia)

A migraine without aura can often be misdiagnosed and is frequently mistaken for:

• A tension type headache - non-throbbing pain which feels like a tight band around both sides of the head

• Sinus headache - pain and pressure in the forehead, cheeks, or around the eyes caused by inflammation and congestion in the sinus cavities.

Chronic Migraine

A chronic migraine is a headache that occurs:

• On 15 or more days per month

• For more than 3 months

• On at least 8 days per month with migraine symptoms

This differs from an episodic migraine which occurs on less than 15 days per month.

This distinction matters because:

• Preventative measures are essential.

• Medication overuse must be addressed.

• Specialist care is often required.

Without appropriate management, an episodic migraine can become chronic. At least 2.5 out of 100 people with episodic migraine will develop chronic migraine each year. This progression is known as ‘transformation’ or ‘chronification’.

Vestibular Migraine

Vestibular migraine is a type of migraine where individuals experience a combination of vertigo, dizziness and balance problems.

These symptoms may occur with the headache, before the headache, or without any headache at all.

According to the ICHD-3, the diagnosis of vestibular migraine requires:

• At least 5 episodes.

• A present or past history of migraine .

• Vestibular symptoms (dizziness or vertigo) lasting between 5 minutes and 72 hours.

• Migraine headache or other migraine associated symptoms in at least half of the episodes.

A vestibular migraine is often misdiagnosed as inner ear disorders (BPPV or Ménière’s) or anxiety/panic disorders.

Silent Migraine (Migraine Without Headache)

A silent migraine, also known as an acephalgic migraine, is when you experience aura symptoms without the throbbing headache.

As the neurological disturbances (the visual changes, tingling, or speech issues) occur on their own, these can easily be mistaken for medical emergencies.

Symptoms of a silent migraine include:

• Zigzag lines

• Flashing lights

• Blind spots

• Nausea

• Numbness/tingling.

These symptoms overlap with more serious conditions such as a stroke or transient ischemic attack (TIA). For this reason, it's important to know how to tell them apart.

For a silent migraine, symptoms usually occur gradually and last no longer than 60 minutes.

You should seek immediate medical attention, by calling 999 if:

• Symptoms occur instantly (like a ‘light switch’).

• You experience symptoms for the first time without a migraine history.

• You experience muscle weakness or drooping on one side of the face/body.

• Symptoms last longer than 60 minutes.

Hemiplegic Migraine

A person with a hemiplegic migraine will suffer a temporary weakness on one side of their body as part of their migraine attack. The word hemiplegic means paralysis on one side of the body.

Symptoms of a hemiplegic migraine are similar to a stroke and can last from 1 hour to several days, but usually go away within 24 hours.

Key features:

• One sided paralysis or weakness

• Visual, sensory or speech aura

• Severe headache.

There are 2 types of hemiplegic migraine:

1. Familial hemiplegic migraine - runs in families. On average, 50% of children who have a parent with hemiplegic migraine will develop this disorder.

2. Sporadic hemiplegic migraine - no known family history. The cause is unknown but could be due to new or sporadic gene mutations.

Triptans are contraindicated in hemiplegic migraine due to vascular risks and instead require specialist management.

Menstrual Migraine

Menstrual migraines are linked to hormonal changes occurring during the menstrual cycle.

If migraine attacks are linked only around the time of your period, it is known as pure menstrual migraine. If however, migraines occur at other times of the month as well as during your period, this is known as menstrually-related migraine.

Menstrual migraines usually occur 2 days before your period starts and continues 3 days into your period.

Frovotriptan is favoured over other triptan medication such as sumatriptan or rizatriptan due to its longer half-life. It stays in the body for longer, suiting menstrual migraines which tend to last longer than other types.

Frovatriptan is also effective as ‘mini-prophylaxis’. For those who can accurately predict their periods, some clinicians suggest taking frovatriptan twice daily for 5-6 days, starting 2 days before your expected period.

Combined hormonal contraception can also be considered to manage menstrual migraine. This contains both oestrogen and progesterone, taking it continuously without a break avoids the sharp drop in oestrogen which may trigger a migraine.

The combined pill is not suitable if you have a migraine with aura or a risk factor for stroke. In this case, the ‘mini-pill’ (progesterone only) may be considered. However, this carries a risk of prolonged or irregular bleeding.

How Is Migraine Type Diagnosed?

The diagnosis of migraine is based on clinical history and guided by ICHD-3 criteria.

A detailed history of symptoms is key for confirming diagnosis. This includes headache characteristics along with the frequency and duration of your attacks.

A headache diary is an efficient way to help identify triggers, timings and patterns. This can help to distinguish the migraine subtype.

It's important to keep an eye out for red flag symptoms. If any of the following are experienced you should seek immediate medical attention:

• Headaches starting within 3 months of a head injury.

• Thunderclap headache - a headache that reaches peak intensity within 60 seconds

• A change in headache pattern

• Neurological symptoms - confusion, weakness, fainting, seizures

• Systemic symptoms - fever, chills, weight loss

• A new onset headache over the age of 50

• Aura lasting for over an hour or symptoms of paralysis

• Headache that worsens when standing or lying down

• Headache triggered by coughing, sneezing or exercise

• Severe eye pain, accompanied by redness, blurriness or double vision

• Swollen and sore temples with or without pain - Temporal Arteritis

When to see a specialist:

• Suspected hemiplegic migraine

• Chronic migraine

• Diagnostic uncertainty

• Poor response to treatment.

Final thoughts

Migraine is not a one-size-fits-all condition. Recognising the different types of migraine is essential for accurate diagnosis, effective treatment and reducing long-term impact.

If your symptoms don't fit a typical pattern, or are changing over time, it is worth seeking medical advice to ensure the correct subtype is identified.