No two migraines are alike. There are several types and subtypes of migraine, and any one patient may experience multiple sorts within their lifetime. Different migraine episodes may also display vastly differing characteristics. The classification and diagnostic criteria of migraine types have evolved with continuing research since the first version of the International Classification of Headache Disorders (ICHD-I) was published 30 years ago. In 2018, the International Headache Society published the third version of the classifications, ICHD-3, and they now claim to be the discipline within neurology with the most systematic classification and explicit diagnostic criteria for every disease entity.1
Multiple faces of migraine – One type does not fit all
The two major types of migraine are:1
- Migraine with aura
- Migraine without aura
However, the debate as to whether migraine with aura and migraine without aura are different entities or just two facets of the same disease is still ongoing.2 Nonetheless, both migraine with and without aura can be characterised as episodic or chronic migraine, based on headache days per month.1 If a migraine occurs on 15 or more days per month for more than three months, it is a chronic migraine.1 In ICHD-3, chronic migraine is classified as its own type, as the frequency or continuity of migraine episodes makes it impossible to distinguish individual migraine attacks.1 Whilst not reported in the UK, a recent US study estimated the prevalence of chronic migraine to be about 9%.3 Although considerably less common, chronic migraine still constitutes a higher societal burden than episodic migraine, as patients with chronic migraine are more disabled, are less productive workwise, and require more support.4
Migraine without aura (formerly also called common migraine) is the most frequent type of migraine, commonly estimated to be experienced by 70–90% of migraineurs.5 During this type of migraine, patients do not experience the sensory or visual warning signs that can precede the headache phase of migraine episodes. The attacks usually last 4–72 hours, and are typically associated with nausea, photo- and/or phonophobia.1,5 Migraine with aura (also called classic migraine), on the other hand, is associated with sensory symptoms – mainly vision changes – that occur immediately before the headache pain sets in, lasting less than an hour.1,6 Between 10–30% of migraineurs commonly experience aura with their migraine attacks.6,7 The pathophysiology of aura is thought to be due to cortical spreading depression (CSD) – a transient wave of neuronal depolarisation.7 Read more on the pathophysiology of migraine here.
Common subtypes of migraine with aura include:1
- Migraine with typical aura
- Migraine with brainstem aura
- Hemiplegic migraine
- Retinal migraine
Migraine with typical aura does not come with any motor, brainstem or retinal symptoms.1 A migraine with typical aura may sometimes even occur without the headache.1,6 Migraine with brainstem aura has additional symptoms to the aura, clearly originating from the brainstem, such as vertigo or tinnitus.1 Hemiplegic migraines include motor weakness, and may be familial or sporadic.1 Retinal migraines involve monocular visual disturbances, such as scintillations, scotoma or blindness.1
One Patient – Differing Migraines
Commonly, a migraine episode may not be classified neatly into one category. Patients may fulfil criteria for more than one type of headache, and an exact classification is often not possible. Therefore, patients may need to be diagnosed with several types of migraine and when this occurs, the diagnoses must be listed in order of importance to the patient.1 However, even within one type of migraine, the symptoms, pain intensity, and duration of migraine can vary greatly for a single patient. A retrospective, cross-sectional analysis of over 28,000 migraine records from 3,900 users gives insight into the great heterogeneity of migraine attacks.8 Self-reported digital diary entries were collected from migraineurs from several European countries using a migraine diary application.8
Results from the study confirm the heterogeneity of migraine in those patient responses that were reviewed. Differences in migraine attack duration, reported pain intensity and impact of migraine on users’ daily activities were observed.8 The majority of users described pain intensity as being moderate (between 5–6 out of 10) irrespective of whether they were episodic or chronic migraineurs.8 Around 29% of patients reported migraine attacks lasting either 0.5–<4 hours or from 8 hours to <1 day in duration.8
Taken together, migraine episodes vary, and patients may need to be diagnosed with several different types of migraine. Monitoring the characteristics and triggers of different migraine attacks – e.g. using diaries – supports the understanding of the unique migraine profiles of individual patients, and may aid in minimising triggers and tailoring the care to each individual’s specific needs.
Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018; 38: 1–211.
Vgontzas A & Burch R. Curr Pain Headache Rep 2018; 22: 78.
Adams AM et al. Cephalalgia. 2015; 35: 563–578.
Lanteri-Minet M. Curr Pain Headache Rep 2014; 18: 385.
The Migraine Trust [Internet]; [updated 2019; cited May 2020]. Available from: https://www.migrainetrust.org/about-migraine/types-of-migraine/migraine-without-aura/.
The Migraine Trust [Internet]; [updated 2019; cited May 2020]. Available from: https://www.migrainetrust.org/about-migraine/types-of-migraine/migraine-with-aura/.
Goadsby PJ et al. Physiol Rev 2017; 97: 553–622.
Vo P et al. Neurol Ther 2018; 8: 321–332.