Hypothalamus as a conductor of the migraine prodrome: A narrative review

OBJECTIVES/BACKGROUND: This narrative review summarizes evidence implicating a role for the hypothalamus in the prodrome phase of a migraine attack. Prodrome is the earliest phase of the migraine attack. Understanding the migraine prodrome could lead to a better description of how migraine attacks are initiated and identification of targets for acute and preventive migraine treatment. The hypothalamus has been implicated in migraine prodrome via (1) localization of common prodrome symptoms to the hypothalamus; (2) identification of neurotransmitters, peptides, and hormones important in migraine pathophysiology for which the hypothalamus influences their production or release; and (3) brain neuroimaging studies identifying changes in hypothalamic activity and functional connectivity during the prodrome and preheadache phases of the migraine attack. METHODS: For this narrative review, PubMed was searched for relevant English language articles using the terms "hypothalamus, prodrome," "hypothalamus, premonitory," "hypothalamus, migraine," "migraine, prodrome," and "migraine, premonitory." The PubMed search was performed on October 29, 2025. Full articles were chosen for review based on their relevance to the three areas defined just above: symptom localization, neuropeptide/neurotransmitter release, and brain imaging. RESULTS: Those with migraine commonly, and often consistently, experience prodrome symptoms, including hypersensitivities to visual and auditory stimuli, neck pain, fatigue, sleep-wake disturbances, changes in appetite, mood changes, and alterations in thermoregulation perception. Many of these symptoms can be localized to functions of hypothalamic subregions and nuclei. Several neuropeptides, neurotransmitters, and hormones that contribute to prodrome and other migraine attack symptoms, including calcitonin gene-related peptide, dopamine, orexins, and pituitary adenylate cyclase-activating polypeptide, are either produced by the hypothalamus or their release is mediated by the hypothalamus. Functional neuroimaging studies of spontaneous and triggered migraine attacks have identified increased hypothalamic activity and altered hypothalamic functional connectivity before migraine headache onset, including during the prodrome. CONCLUSION: There is compelling evidence that the hypothalamus plays a role in the migraine prodrome and likely in migraine attack initiation. This is supported by many migraine prodrome symptoms localizing to hypothalamic function and functional neuroimaging studies demonstrating increased activity and altered connectivity of the hypothalamus during the prodrome phase. Further evidence and research are required to understand the hypothalamus' contribution relative to other brain regions.