Yawning and neck stiffness before migraine
The premonitory phase in migraine is the period hours or days before the onset of headache with symptoms including headache, yawning, mood changes, or changes in appetite. The symptoms that occur during the premonitory phase suggest involvement of the hypothalamus, brainstem, limbic system, and certain cortical areas,1 which has been recently supported by neuroimaging studies.2,3 An ePoster on premonitory symptoms in patients with episodic migraine, presented by Dr. Bülent Güven (University of Health Sciences, Ankara, Turkey) at the virtual 6th Congress of the European Academy of Neurology (EAN) held 23–26 May 2020, provided insight into the frequency of symptoms occurring during the premonitory phase of migraine attacks and its association with different characteristics of migraine.
Neck stiffness and yawning are the most common premonitory symptoms
In the study presented by Dr. Güven, 330 patients with migraine with or without aura were prospectively recruited from a neurology outpatient clinic and followed up for 1 or 4 months based on the frequency of migraine. Through the use of questionnaires and headache diaries, premonitory associated symptoms and characteristics of the patient’s migraine attack were recorded.
The study revealed that 59.4% of patients reported premonitory symptoms during migraine attacks. The most commonly reported ones were neck stiffness in 21.2% of the study population, followed by yawning in 19.1% of patients and irritability/anxiety in 16.4% of patients. These data support those of an earlier study by Güven et al.1 in which yawning was shown to be a common self-reported symptom in the premonitory phase.
Premonitory symptoms are associated with age, gender, and migraine with aura
The study presented by Dr. Güven also looked into the demographic and clinical characteristics of patients with migraine and premonitory symptoms. Dr. Güven presented the results of a univariate logistic regression analysis, which revealed that a number of factors were statistically and significantly associated with premonitory symptoms, including age, gender, migraine with aura, and duration of disease. Other factors including severity of headache, unilateral and bilateral lateralization of pain, accompanying vomiting, photophobia, cranial autonomic symptoms and cutaneous allodynia, and relation to menstruation, were also found to be statistically and significantly associated with premonitory symptoms.
Longer disease duration and diversity of accompanying symptoms in patients with premonitory symptoms may suggest that these symptoms facilitate the occurrence of each other and reflect the increase in brain excitability over time.
More premonitory symptoms in patients with long duration of disease
Patients were also asked to report on the number of premonitory symptoms occurring during migraine attacks. Whereas most patients (91) experienced only one premonitory symptom, 2–3 premonitory symptoms were reported by 59 patients and more than 3 premonitory symptoms by 46 patients. It was found that the duration of migraine disease was longer for patients with 2–3 or 3 premonitory symptoms than for patients with only 1 premonitory symptom.
The hypothalamus has an important role in the premonitory phase
Neck stiffness and yawning were seen to be the most commonly reported premonitory symptoms in the patient population included in Dr. Güven’s study. Patients with premonitory symptoms also reported more severe headaches and the presence of more frequent non‑headache symptoms. In Dr. Güven’s opinion, the results of this study can be explained with the role of the hypothalamus in modulating pain and alterations in complex networks involving areas of the cortex, thalamus, and brainstem. This study provides further evidence on the prevalence of premonitory symptoms in patients with migraine. Such studies are essential in furthering research in to the enigmatic premonitory phase of migraine, which together with recent brain imaging studies,2 are providing more insights into migraine onset.
Güven B, Güven H, Çomoğlu SS. Migraine and Yawning. Headache 2018;58:210-6.
Karsan N, Goadsby PJ. Imaging the Premonitory Phase of Migraine. Front Neurol 2020;11:140.
Gago-Veiga AB, Vivancos J, Sobrado M. The premonitory phase: A crucial stage in migraine. Neurologia 2017.
