Migraine is not a single disorder but a family of related conditions, each classified by its own set of symptoms, duration, and associated neurological features. The International Classification of Headache Disorders, now in its third edition (ICHD-3), recognizes more than a dozen migraine subtypes and complications, ranging from the common migraine without aura to rare forms involving temporary paralysis or vision loss in one eye. Roughly 16% of the world’s population experiences migraine, but the experience varies so widely from person to person that two people with “migraine” may have almost nothing in common beyond the label.
Migraine Without Aura
This is the most common form, accounting for about two-thirds of all migraine cases. Attacks typically involve moderate-to-severe pulsating pain on one side of the head, lasting anywhere from four to 72 hours if untreated. Nausea, sensitivity to light, and sensitivity to sound are the hallmarks. There is no preceding warning phase of visual disturbances or tingling, which is what distinguishes it from migraine with aura.
The underlying biology involves activation of pain-signaling pathways connecting the brainstem and the blood vessels around the brain. Researchers have long debated whether a phenomenon called cortical spreading depression, a slow wave of electrical activity across the brain’s surface, plays any role in attacks that lack aura symptoms. So far, evidence for “silent” spreading depression events in migraine without aura remains unconfirmed.1PubMed Central. Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, CSD, sensitization and modulation of pain In practice, the distinction matters because people who never experience aura have a different risk profile for certain complications, particularly stroke, than those who do.
Migraine With Aura
About one-third of people with migraine experience aura, a set of temporary neurological symptoms that usually develop before the headache phase begins. The most common aura is visual: a flickering, uncolored zigzag line that starts near the center of the visual field and gradually drifts outward toward the edge of one side, often leaving a blind spot in its wake. Sensory aura typically starts as tingling in one hand, creeps up the arm, and then affects the face and tongue. Some people also experience speech difficulties.2Brain. A nosographic analysis of the migraine aura in a general population
Aura symptoms tend to build gradually over several minutes and then fade. In a detailed study that tracked individual attacks, visual symptoms lasted a median of 30 minutes, while sensory and speech symptoms lasted about 20 minutes each. However, visual aura lasted longer than an hour in roughly 14% of attacks, and about a quarter of patients had at least one aura episode where a single symptom stretched past the 60-minute mark.3PubMed. Migraine aura symptoms: Duration, succession and temporal relationship to headache When multiple aura symptoms occur in the same attack, they tend to appear in sequence rather than all at once, with each new symptom starting during or just after the previous one fades.
The ICHD-3 diagnostic criteria for migraine with aura have been refined over successive editions. The current version achieves excellent specificity, correctly ruling out other conditions in about 96% of cases for migraine with aura generally, and 98% for the “typical aura” subtype.4PubMed Central. ICHD-3 is significantly more specific than ICHD-3 beta for diagnosis of migraine with aura and with typical aura That high specificity matters because aura-like symptoms can also signal far more serious conditions, including stroke.
Hemiplegic Migraine
Hemiplegic migraine is one of the most alarming subtypes because it includes temporary weakness or paralysis on one side of the body, mimicking a stroke. The weakness usually affects the hand and arm and can last from minutes to days. Because the symptoms overlap so heavily with stroke, emergency evaluation is almost always warranted during a first attack.
There are two recognized forms. Familial hemiplegic migraine runs in families and follows an autosomal-dominant inheritance pattern, meaning a child needs to inherit only one copy of the relevant gene variant from one parent to be affected. Mutations have been identified in three genes: CACNA1A, ATP1A2, and SCN1A.5PubMed. The genetic spectrum of a population-based sample of familial hemiplegic migraine A screening study of hemiplegic migraine families identified several specific mutations in CACNA1A and ATP1A2, including both previously known and novel variants.6PubMed Central. Screening of CACNA1A and ATP1A2 genes in hemiplegic migraine: clinical, genetic, and functional studies Sporadic hemiplegic migraine presents the same way but occurs in people with no family history. Whether the sporadic form involves the same genes or different mechanisms is still being studied.
Hemiplegic migraine can also come with additional features not seen in typical migraine, including confusion, fever, and in rare cases prolonged coma-like states. Because of the genetic component, genetic testing is sometimes useful for confirming the diagnosis and informing family members about their risk.
Migraine With Brainstem Aura
Previously known as basilar-type migraine, migraine with brainstem aura involves aura symptoms that originate from the brainstem or affect both sides of the brain simultaneously. The typical symptoms include vertigo, slurred speech, double vision, ringing in the ears, unsteady gait, and sometimes a decreased level of consciousness.7PubMed Central. Migraine with Brainstem Aura Accompanied by Disorders of Consciousness
A study examining 44 patients who met the ICHD-3 criteria found that most had two or three brainstem aura symptoms per attack. Ataxia (unsteady movement) and a decreased level of consciousness were the most common, followed by vertigo, double vision, slurred speech, and ringing in the ears. Importantly, nearly three-quarters of these patients also experienced typical migraine aura, particularly visual disturbances, alongside their brainstem symptoms. Bilateral visual disturbances or bilateral sensory symptoms appeared in 45% of cases.8Brain. Migraine with brainstem aura: defining the core syndrome
This overlap with typical aura means brainstem aura migraine often goes unrecognized. Clinicians may focus on the visual or sensory symptoms and miss the brainstem features, or conversely, focus on the dizziness and consider inner-ear disorders instead. The disorder is rare enough that many general practitioners may never see a clear case.
Retinal Migraine
Retinal migraine involves repeated episodes of visual disturbance, sometimes including complete temporary blindness, in one eye only. This is the key distinguishing feature: while typical migraine aura produces visual symptoms in both eyes (because it originates in the brain’s visual cortex), retinal migraine affects just one eye because the problem involves the blood supply to the retina itself.
A systematic review found that retinal migraine is characterized by monocular symptoms in about 90% of cases, with scotomas (blind spots) appearing in 84% and transient vision loss occurring in up to 100% of confirmed cases. Episodes usually last under 60 minutes in about 89% of attacks, though some can stretch longer. The underlying mechanism is vascular, involving temporary spasm or reduced blood flow in the retinal vessels, rather than the cortical spreading depression that drives typical aura.9PubMed Central. Differentiating Visual Symptoms in Retinal Migraine and Migraine With Aura: A Systematic Review of Shared Features, Distinctions, and Clinical Implications In rare cases, permanent vision loss can result, which is why any new episode of monocular visual loss should be evaluated urgently.10PubMed. The role of visual system in migraine
One practical challenge is distinguishing retinal migraine from typical aura. In typical migraine with aura, visual symptoms are bilateral or affect the same side of the visual field in both eyes, even though people often perceive them as affecting only one eye. Covering each eye in turn during an episode is the simplest test: if the disturbance persists in both eyes separately, it is likely typical aura; if it disappears when you cover the affected eye alone, it may be retinal migraine.
Vestibular Migraine
Vestibular migraine is probably the most underdiagnosed form. The hallmark is episodic vertigo or dizziness that occurs alongside a history of migraine, even though a headache does not always accompany the dizzy spells. The diagnostic criteria require recurrent vestibular symptoms of moderate or severe intensity, lasting between five minutes and 72 hours, with a temporal connection to other migraine features like light sensitivity or nausea.11PubMed Central. Vestibular migraine: Diagnostic criteria
The condition sits at a tricky diagnostic crossroads. Some patients develop mild hearing loss over time, which can make the picture look like Ménière’s disease, an inner-ear disorder with overlapping symptoms. A follow-up study of patients initially classified with vestibular migraine found that some later met formal criteria for bilateral Ménière’s disease based on hearing loss alone, even though their overall clinical presentation was more consistent with migraine.12PubMed. Vestibular migraine–validity of clinical diagnostic criteria The overlap means people sometimes receive the wrong diagnosis, leading to treatments that do not address the underlying migraine biology.
Aura Without Headache
Sometimes called “silent migraine,” this involves the full aura experience, including visual disturbances, sensory symptoms, or even brainstem aura features, without any headache following. It commonly presents as a visual aura alone and can also emerge later in life, a phenomenon sometimes referred to as late-onset migraine accompaniment.13PubMed. Migraine Aura Without Headache
This variant causes particular anxiety because many people experiencing visual disturbances without headache assume something more serious is happening. In middle-aged and older adults, a new onset of visual zigzags or fleeting blind spots triggers concern about stroke or retinal detachment. The diagnosis is made by confirming that the symptoms match the typical aura pattern, that they resolve fully, and that other causes have been excluded. People who had migraine with aura in their younger years and then “lose” the headache phase in their forties or fifties are a well-recognized group.
Chronic Migraine and Its Relationship to Episodic Migraine
The line between episodic and chronic migraine is drawn at 15 headache days per month, sustained for at least three months. When episodic migraine tips into this pattern, the process is called chronification. A growing body of evidence points to central sensitization, a state in which the brain’s pain-processing circuits become more reactive over time, as a key driver. Central sensitization is also thought to underlie cutaneous allodynia, where ordinary touch on the skin of the face or scalp becomes painful during or between attacks.14PubMed Central. Central Sensitization in Migraine: A Narrative Review
The classification of chronic migraine itself has evolved. The first edition of the international headache classification did not include it at all. The second edition introduced the term but defined it in a way that looked more like frequent episodic migraine than a distinct clinical entity. The current edition allows for a more nuanced diagnosis, including cases where medication overuse headache coexists with chronic migraine.15PubMed Central. The evolving classifications and epidemiological challenges surrounding chronic migraine and medication overuse headache: a review That coexistence matters, because overuse of acute painkillers is one of the most common drivers of chronification. In one study of patients with transformed migraine and medication overuse, about 71% of those who successfully stopped overusing their medications returned to an episodic pattern.16PubMed. Transformed migraine and medication overuse in a tertiary headache centre–clinical characteristics and treatment outcomes
Pediatric Variants and Abdominal Migraine
Children experience migraine differently from adults, and several recognized subtypes occur mainly in childhood. Abdominal migraine is one of the most distinctive: recurrent bouts of moderate-to-severe belly pain, often accompanied by nausea, vomiting, pallor, and loss of appetite, with the child returning to completely normal health between episodes. It affects roughly 0.2% to 4.1% of children.17PubMed Central. Review of Abdominal Migraine in Children
Abdominal migraine and a related condition, cyclical vomiting syndrome, share overlapping features with conventional migraine but lack its defining symptom: headache. Both are characterized by recurrent attacks of nausea, vomiting, and abdominal pain lasting hours to a few days, with symptom-free intervals in between. Children with these conditions often go on to develop typical migraine headaches as they grow older, which is why they are classified as migraine-related syndromes.18PubMed. Abdominal migraine and cyclical vomiting syndrome Although these conditions primarily affect children, they can also present for the first time in adults, which can lead to prolonged diagnostic confusion since clinicians may not think of migraine when the chief complaint is stomach pain.19PubMed Central. Brain to Belly: Abdominal Variants of Migraine and Functional Abdominal Pain Disorders Associated With Migraine
Menstrual Migraine
Menstrual migraine is defined by attacks that consistently occur around the start of menstruation, typically within a two-day window before to three days after the onset of bleeding. The dominant theory is the estrogen withdrawal hypothesis: the natural drop in estrogen levels just before a period acts as a trigger for the migraine attack.20PubMed Central. Menstrual migraine is caused by estrogen withdrawal: revisiting the evidence
This subtype is further divided into “pure menstrual migraine,” where attacks occur only around menstruation and at no other time, and “menstrually related migraine,” where attacks are reliably triggered by menstruation but also happen at other times of the month. The distinction has practical treatment implications. Pure menstrual migraine can sometimes be managed with short-term preventive strategies timed to the menstrual window, while menstrually related migraine usually requires a broader prevention approach. Hormonal contraceptives, hormone replacement therapy, and perimenopause can all shift the pattern, sometimes improving symptoms and sometimes making them worse.
Complications of Migraine
The ICHD-3 also classifies complications that can arise from migraine attacks themselves. Status migrainosus refers to a debilitating migraine attack that persists continuously for more than 72 hours. A population-based study found that these prolonged attacks had a median duration of about five days, with nearly 15% of patients experiencing a recurrence, typically within a couple of months.21PubMed Central. Incidence of Status Migrainosus in Olmsted County, Minnesota, United States: Characterization and Predictors of Recurrence
Migrainous infarction is rarer and more serious: a stroke that occurs during a migraine with aura attack, where the aura symptoms do not fully resolve and brain imaging confirms an area of infarction in the corresponding part of the brain. It occurs predominantly in the posterior circulation, the blood supply to the back of the brain that handles vision and coordination, and is most common in younger women with a history of migraine with aura.22PubMed. Clinical and MRI characteristics of acute migrainous infarction Despite the alarming name, migrainous infarction is genuinely rare, but it underscores why tracking aura symptoms carefully and reporting any sudden change in their pattern is important.23PubMed. Migrainous infarction: aspects on risk factors and therapy
When Other Conditions Mimic Migraine
Getting the classification right is not purely academic. A number of serious conditions can produce headaches that look almost exactly like migraine, meeting the clinical criteria for migraine without aura or migraine with aura while actually being caused by something else entirely. A study examining headaches that mimicked migraine found that the migraine-like headache was attributable to another cause in roughly 13% of people having transient ischemic attacks, about 7% of those with ischemic strokes, 44% of those with intracranial aneurysms, 52% of those with a condition that raises brain pressure, and up to 90% of those with persistent post-traumatic headache.24PubMed Central. Migraine-like headache attributed to a causative disorder: primary migraine or secondary headache with a migraine-like phenotype?
The clue that something is off is often the treatment response. These migraine-like headaches caused by secondary disorders frequently respond poorly to standard migraine treatments. In many cases, headaches resolved after the underlying condition was treated, such as clipping an aneurysm or managing elevated brain pressure. This would not happen with true primary migraine. Recognizing these mimics is essential because the consequences of misdiagnosis range from delayed surgery to missed strokes.25Neurology Perspectives. Review Similarities and differences between migraine and other types of headaches: Migraine mimics
The Overlap Between Migraine and Mental Health
Migraine of all types has a well-documented bidirectional relationship with depression: each condition raises the risk of the other. This is not simply a matter of chronic pain making people depressed, or depressed people noticing pain more. Research suggests shared biological pathways, including alterations in serotonin signaling and overlapping inflammatory markers, that predispose the brain to both conditions.26PubMed Central. The exploration of mechanisms of comorbidity between migraine and depression
The relationship has practical consequences for classification and treatment. A person with chronic migraine and comorbid depression is likely to have a harder time responding to standard migraine preventives, may be more susceptible to medication overuse, and may benefit from treatments that address both conditions simultaneously. Some of the most commonly used migraine preventives, including certain antidepressants, were originally developed for mood disorders and only later found to reduce headache frequency. Recognizing the overlap at the classification stage rather than treating migraine in isolation tends to lead to better outcomes and fewer cycles of failed treatment.