How Long Does a Migraine Last? 2023
The Bible for headache diagnosis, the International Classification of Headache Disorders (ICHD) v. 3, provides specific medical information about all headaches. ICHD states that an episode of Migraine may 4 to 72 hours. This is for a single, individual Migraine episode. In general most Migraines last 4 to 5 hours, with long ones lasting 24 hours.
Related questions
What is Chronic Migraine?
Chronic Migraine is defined as the occurrence of 15 headache days a month for 3 months in a row, 8 of which have Migraine features. Chronic Migraine is usually due to medication overuse syndrome, a headache problem caused by taking too much headache medicine. Many individual sufferer continuous headache of the Migraine type continuously for days, weeks, months, and sometimes years at a time.
Migraines may come out of the blue for no reason while tension type headaches usually comes at time of stress and are not as bad as a Migraine.
But then, some persons have long lasting bouts of headache that make them really sick, down in bed, afraid of light and sound, nauseated and vomiting repeatedly with severe headaches. What is this? How long does a Migraine last? What have I got they wonder?
Read about my Mini ebook on Migraine here.
This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, migraine textbook author, podcaster, YouTube video producer, and blogger.
Why is that Migraines can last 4-72 hours?
The specific definition of how long a Migraine headache lasts is not the work of some vaulted neurologic panel of headache doctors. The time frame of 4 to 72 hours has to do with the way the human brain works.
By definition of the International Classification of Headache Disorders v3. a single attack of Migraine headache may last 4 to 72 hours. This reference of time, delimiting an episode of headache is helpful in differentiating Migraine from other types of headaches.
The Migraine process causes the release of 3 inflammatory neurochemicals, Neurokinan A, Substance P, and Calcitonin Gene-Related Peptide (CGRP). CGRP is produced in both peripheral and central neurons.
CGRP is an active vasodilator and functions to transmit nociception, or pain. In the cerebral trigeminal vascular system, the cell bodies of the trigeminal ganglion are the main source of CGRP.
The start of the headache part of a Migraine begins with release of these 3 neurochemicals, which then drain out of the brain via the jugular vein, are metabolized in the liver, and released from the body in the toilet. It takes 4 to 72 hours for this process to occur. This is the reason a Migraine may last from 4 to 72 hours. It is a process dictated by human metabolism and not some headache committee.
What is the difference between episodic and chronic Migraine?
Episodic Migraine is defined as 14 or less headaches a month, while chronic Migraine is 15 or less headaches a month, 8 of which have Migraine features. An episode of Migraine stands out as an event of headache, nausea, vomiting, sensitivity to light and sound, and the need to be down.
Persons with chronic Migraine may have these same features every day, or 80-90% of the time, so that it seems to the afflicted individual to be just one big headach time or nearly continuous headache. The timespan of headache being 4-72 hours may be lost with this kind of Migraine since the headaches are continuous.
Does Migraine have different phases?
The Migraine syndrome has 4 individual phases: Prodrome, Aura, Headache, and Postdrome and the following analysis refers to Migraine persons who suffer an untreated Migraine.
Prodrome Phase This first phase of migraine comes on for hours to a day before the attack. Prodrome symptoms can be mood changes, irritability, excitability, depression, yawning, food craving, and urination.
Aura Phase. Approximately 30% of persons with Migraine have an aura. The most common aura here are visual changes of seeing zig-zag images, black holes, or half of things.
Some persons have a spreading numbness or tingling which moves across the arm, to the hand, and then the same side of the face, lips, or tongue. As the tingling moves up there is clearing of the involved anatomical location that happened earlier. Tingling in the right little finger may move to the ring finger and then the middle finger but by the time numbness is to the middle finger the little finger numbness has cleared.
A smaller number of persons may develop aphasia which difficulty in understanding words and speaking. The order of symptoms here is always visual symptoms before numbness before aphasia. All these aura symptoms by ICHD criteria should clear within 60 minutes.
Headache Phase Headache can last 4 to 72 hours and is a headache with true Migraine features, being one-sided, severe, throbbing, associated with nausea or vomiting, and sensitivity to light and sound. Untreated the severity of headache is worse on day 1 and better by day 3.
One survey of 1100 Migraine patients published in May 2020 in Headache reported that 44% of people said that their Migraine headache phase usually lasts up to 24 hours. Thirty-three and a third of patients had headaches lasting longer than 24 hours.
Postdrome Phase At this time most persons have little or no headache pain but many of them do not feel normal. This feeling may last 24 to 48 hours. During this time people say they are not as sharp and feel hungover, while some feel up, elated, hyper, or euphoric. Many Postdrome Migraine patients report pain on just touching their head, a symptom called allodynia where touch is perceived as painful.
Why do many persons with Migraine only have headache for a short time?
Early treatment of a Migraine in 10, 15, or 20 minutes may come for persons treating quickly and at onset of their Migraine with a triptan, especially the quick acting triptans like subcutaneous 6 mg sumatriptan, or 5 mg zolmitriptan nasal spray which both work in 10 minutes. Intramuscular or nasal spray DHE and eye drop timolol could also be included in the quick acute onset list of drugs for Migraine.
The other oral triptans such as rizatriptan, almotriptan, and eletriptan take at least 30 minutes to work and the longer duration triptans such as naratriptan and frovatriptan take 1-2 hours to kick in.
Subcutaneous Triptans
Then, there is the issue of when during the phases of Migraine, a patient treats. I always encourage patients to treat during prodrome if they can accurately define it. This would be treating really before the headache part begins.
The 30% of patients who have an aura, which usually starts as a visual aura, should all treat at onset of aura with a triptan. The other 70% of patients who have Migraine without aura and who cannot identify their prodrome should treat their Migraine at the onset of the headache itself.
In general, acute treatment of Migraine with a triptan gives a 2-hour headache free response for 70-80% of persons, making triptans still the best drugs for treating Migraine, treating more quickly and cheaper than even the new drugs for acute therapy,
The new acute treatment drugs like Reyvow, Nurtec ODT, and Ubrelvy are all name brand drugs, so they are more expensive than triptans. I like to call them the new 2020 Migraine acute therapy drugs.
Listed product information for the new drugs states that Nurtec ODT “provides pain relief in 1 hour,” Ubrevly provides freedom from headache pain at 2 hours for 20% of patients and the advertising drug information for Reyvow says that it “could provide fast and complete pain relief in two hours.”
David Rind, MD, the chief medical officer of ICER said regarding the use of Nurtec, Reyvow, and Ubrevly “For patients who are unable to take triptans or who don’t get adequate benefit from those more affordable options, these new migraine therapies appear to relieve migraine symptoms in 10% to 20% more patients than who respond to placebo.”
The triptans work for more persons and usually faster than the new 2020 Migraine drugs. The point of this information regarding treatment is that how all the drugs for acute therapy for Migraine work determines the key question of this article, namely How Long Does a Migraine Last?
The bottom line is that adequate, quick Migraine treatment and avoidance of overtreating determine how long a Migraine lasts.
What happens to Migraine patients who get a week or two, or a month, or years of daily Migraine?
They start having longer lasting, more frequent headaches. They develop Chronic Migraine because they are overtreating with headache drugs,
This group of patients is likely making the following mistakes to prolong the duration of the Migraine:
They are not using a triptan or one of the new 2020 drugs for treatment. They are using over the counter drugs for treatment like Excedrin, ibuprofen, Tylenol, or naproxen which may provide a little or a lot of headache relief, but many times they are not enough to end the headache. The problem is when they keep taking the drugs too often, then they may develop transformation of Migraine from episodic to chronic Migraine.
Another scenario is that some migraineurs may use a drug that provides adequate treatment, like a triptan, but they do not treat at the onset of the Migraine. They treat too late and if they use a triptan they do not have a 2-hour headache free experience. Their headaches continue and last longer.
It is said that treating with a triptan anytime during a Migraine will help some, but it will not provide a 2-hour headache free experience if the triptan is not taken at onset.
What is the Migraine Timing Cycle?
It is generally thought that local vasodilatation of intracranial extracerebral blood vessels and a consequent stimulation of surrounding trigeminal sensory nervous pain pathways is a key mechanism underlying the generation of headache pain associated with migraine.
This activation of the 'trigeminovascular system' is thought to cause the release of vasoactive sensory neuropeptides, especially CGRP, that increase the pain response. The activated trigeminal nerves convey nociceptive, or pain, information to central neurons in the brain stem trigeminal sensory nuclei that in turn relay the pain signals to higher centers where headache pain is perceived.
It has been hypothesized that these central neurons may become sensitized as a migraine attack progresses. The triptan anti-migraine agents (e.g., sumatriptan, rizatriptan, zolmitriptan, eletriptan, frovatriptan, and naratriptan) are serotonergic agonists that have been shown to act selectively by causing vasoconstriction through 5-HT1B receptors that are expressed in human intracranial arteries and by inhibiting nociceptive transmission through an action at 5-HT1D receptors on peripheral trigeminal sensory nerve terminals in the meninges and central terminals in brain stem sensory nuclei.
These three complementary sites of action underlie the clinical effectiveness of the 5-HT1B/1D agonists against migraine headache pain and its associated symptoms.
The Migraine timing cycle spelled out.
1 Trigeminal activation and cerebral arterial vasodilation.
2 20-40 minutes later the neurochemicals CGRP, Neurokinin A, and Substance P are released by the migraine process from ganglia to inflame the trigeminal nerve, the arteries, and later the thalamus.
3 At 2 hours the arteries vasodilate and are inflamed. Blood pulsing through dilated, inflamed arteries causes pulsatile, pounding headache.
4 Past 3 hours the thalamus, also known as the pain center of the brain is turned on by the migraine process.
The Migraine Timing Cycle
Migraine is an episodic disorder of headache lasting 4-72 hours. After a migraine within a day or so the neuropeptides in the brain are metabolized and leave the body in a few days through the liver and then the toilet.
However, if one over treats with certain drugs (caffeine, NSAIDS, Tylenol, pseudoephedrine, triptans, hydrocodone, or butalbital drugs) then these painkiller drugs drive the cylic production of the inflammatory neurochemicals and the headache keeps on going.
I tell patients the drugs they are taking are like putting gasoline on a fire, which then burns longer.
At that point episodic migraine may be transformed to Chronic migraine which is defined as >15 headache days a month, eight of which meet the criteria for migraine.
This occurs because the body does not have enough time to eliminate the drugs or the released neuropeptides and they stay in the brain and activate this system so that 1-2-3-4 of the Migraine cycle occur continuously, resulting in frequent, oftentimes daily headache.
In the 1988 International Classification of headache this overtreatment syndrome was named “Rebound headache,” but now this term has been replaced by “Medication Overuse Headache.” This is a common headache diagnosis and problem, comprising about 80-90 % of first visits to a headache specialist.
The international classification of Headache states that in general all migraine patients should limit caffeine, painkillers, and triptans to only 2 days a week. This is the most that the body can tolerate and get rid of the drug and the neurochemicals without transforming into more frequent headaches.
Medication Overuse Headache relates intimately to how long a Migraine headache lasts. Persons who overtreat all have long lasting Migraines, at durations longer than the textbook time of 4-72 hours.
Chronic Migraine is a term used for a patient who has headache over 15 days a month, 8 of which have migraine features. A significant number of these patients have MOH which is now 80-90% of new patients seen in specialty headache clinics and affects 4 million people yearly.
Medication overuse headache (MOH) occurs after pain killers or analgesics are taken frequently for headache. The headache pattern from this overtreatment often results in the occurrence of severe, daily, disabling headaches. These headaches usually have Migraine features of being severe, throbbing, and associated with nausea and vomiting, and sensitivity to sound and light.
MOH occurs mainly with Migraine patients and rarely with Tension Type Headaches. There is a common pattern of transformation from rare or episodic Migraine (less than 15 headache days a month) to Chronic Migraine. This transformation occurs gradually over weeks to months.
Many patients fluctuate in and out of Medication Overuse Headache depending on how bad their headaches are and how much medicine they take to treat it.
MOH is a concerning, disabling, well known, worldwide problem. It is the number 1 diagnosis for new patients to a headache practice and affects 1% to 2% of the general population. The problem with medication overuse headache is that patients typically rotate to different drugs and take many drugs at the same time that causes or worsens the headaches.
What are the drugs that are usually cause Medication Overuse Headache?
The International Classification of Headache Disorders (ICDH) 3 describes frequent headache from the following classes of drugs:
Triptans taken more than 10 days a month.
Non-opioid analgesic drugs such as caffeine, acetaminophen, ibuprofen, or naproxen more than 15 days a month.
Butalbital or opioid narcotics taken more than 10 days a month.
The bottom line regarding the duration of a Migraine attack is that it is usually 4-72 hours, unless the Migraine victim is overtreating with headache medication. Then, who knows how long the headaches may last.
I once saw a woman who started taking 6 Advil a day at the advice of her mother when she was 6 years old and I saw her in her sixties when she came in for daily headaches.
Check out my big book on Migraine here.
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All the best.
Britt Talley Daniel MD