Migraine with Aura 2023
Migraine is an inherited/familial chronic neurologic condition characterized by recurrent, usually one-sided headache, nausea and vomiting, and sensitivity to light and sound. It generally comes in recurrent attacks lasting 4 to 72 hours. It is present in women three times as often as in men. The incidence of migraine and women is 25% and in men 6%. Approximately 12% of the world population has migraine. It is a very severely disabling medical condition.
Migraine is usually treated at the general practice or internal medicine level and after that persons with migraine see a neurologist or a headache specialist. For a neurologist in general practice, migraine is the most common problem they see.
In general, there are two types of migraine, migraine without aura and migraine with aura. What is the big difference? What is Migraine with Aura?
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.
Migraine with aura is a regular migraine headache with a visual aura. Rarely there may be numbness of the hand and face or trouble talking. This aura consists of seeing half of things, dots, or arc like images. Numbness or tingling may slowly progress up the hand to the arm and cheek. Rarely there may be difficulty speaking.
A migraine headache is usually one-sided, severe, 4-72 hours duration, associated with inactivity, and comes with nausea and vomiting and sensitivity to light or sound.
The visual aura is due to an electrical wave that slowly moves across the visual cortex of the brain. The visual cortex is in the occipital lobe in the back part of the brain where vision is processed. The wave spreads across the occipital lobe producing a perceived visual image that moves across the person’s visual field on one side or the other.
A common visual aura looks like the top part of a fort and is called a “fortification spectrum” because of this. These images often assume a C-shape or boomerang shape that shimmers and flashes. There may be zig-zag lines with the aura. Often within the aura there is a central visual loss called a scotoma which produces a “blind spot.”
Sensory symptoms may accompany the visual aura starting as a feeling of pins and needles or tingling which may start laterally on the little finger and then spread to successive fingers till it gets to the thumb, clearing up in the small fingers as it goes. Then sensory tingling goes to the hand, forearm and the cheek and tongue all on the same side.
Some persons will also have trouble speaking normally and cannot name things well or read or write. This is termed dysphasia or aphasia.
Related questions
What is migraine with aura like according to the International Classification of Headache Disorders (ICHD3), the so-called “Bible” for headache?
Consider my mini eBook on Migraine here.
ICHD 3 states that Migraine with aura has:
A. At least 2 attacks fulfilling criteria B-D
B. Aura consisting of at least one of the following, but no motor weakness:
1. fully reversible visual symptoms including positive features (e.g., flickering lights, spots or lines) and/or negative features (i.e., loss of vision)
2. fully reversible sensory symptoms including positive features (i.e., pins and needles) and/or negative features (i.e., numbness)
3. fully reversible dysphasic speech disturbance
C. At least two of the following:
1. homonymous visual symptoms and/or unilateral sensory symptoms
2. at least one aura symptom develops gradually over 5 minutes and/or different aura symptoms occur in succession over 5 minutes
3. each symptom lasts 5 and 60 minutes
D. Headache fulfilling criteria B-D for 1.1 Migraine without aura begins during the aura or follows aura within 60 minutes.
E. Not attributed to another disorder.
What is the headache like in persons with Migraine with aura?
These persons may have typical migraine headaches which are one-sided, throbbing, associated with sensitivity to light, sound, and odors, and coming with nausea and vomiting. However, for many persons the headache part of the syndrome is less severe than an attack of migraine without aura. For some persons there is no headache, but only the visual aura.
These headaches last 4 to 72 hours and come in a recurrent cyclical pattern following triggers, or aggravating factors.
Migraine—in bed, sick, sensitive to light, pain on one side.
What terms were previously used for migraine types?
The 1962 JAMA classification for migraine called migraine without aura “common” migraine and migraine with aura “classical” migraine.[i]
The International Classification Of Headache Disorders in 1988 changed the terms to migraine without aura and migraine with aura. [ii]
Is there a difference in the stroke risk between the two types of Migraine?
Yes, Migraine with aura has a 6 % incidence of stroke which is not shared by the Migraine without aura group. The worst stroke risk is a young lady with Migraine with aura who smokes and who takes an estrogen based birth control pill. The stroke risk here goes up to 30% or so.
Is there a difference in treatment of migraine without aura and migraine with aura?
No, both disorders are treated similarly. All patients with migraine should learn to do the migraine lifestyle. Patients generally should use one of the cheap, generic triptans for acute management of migraine headaches when they come on. Some patients will respond to simple nonprescription drugs such as Excedrin, Advil, or naproxen.
Both types migraine will respond to preventive medications when necessary for patients who qualify for that or who have a lot of headaches and prefer to take medicine daily for headache. These include the old drugs of amitriptyline, topiramate, beta blockers, and Depakote, only for nominal fertile women. Headache doctors have moved quickly to the new CPRP drugs which are given either by subcutaneous injection or IV infusion monthly. These new drugs have worked very well.
It seems that many persons with migraine with aura would realize what they have.
Diagnosis is a problem in headache anyway. Only 56% of persons with Migraine have ever had a diagnosis made by a doctor. But in many cases these patients know exactly what their diagnosis is and have known it since they were a child or a teenager and they had their first visual attack which resulted in a hurried, dramatic visit to a reassuring ophthalmologist or neurologist.
These patients may come in later for treatment and sometimes for MRI scanning to be certain that the diagnosis is truly migraine and not something else more worrisome like an aneurysm, a TIA, which is a warning of a stroke, or a stroke.
Do any patients have both migraine with and without aura?
Occasionally patients have both migraine with and without aura where the predominant headache type is usually migraine without aura.
Don’t some migraine patients have the aura without headache?
Some patients have only the aura symptoms and no headache so they are not aware that migraine is the problem they have been having. This used to be called “migraine sine hemicrania” where sine is Latin for “without” but ICDH-3 calls this ”Typical aura without headache.”[iii] This is also called “silent” migraine and “acephalic” migraine.
A large portion of these patients are middle aged women who swear they have never had a migraine or any other significant headache in their life. Sometimes they may admit they also have “sinus headaches” which on close analysis resemble migraine without aura and they may have a number of migraine links--like motion sickness, hungry headache, menstrual headaches, and the like.
What is the spreading wave of polarization or depression about?
The visual images which slowly trace across the patient’s visual field come from migraine induced spreading waves of depolarization occurring in the occipital cortex of the brain. This statement requires some explanation. Light enters the eye through the pupil, is focused as it passes through the lens, and then it impacts on the light sensitive tissue of the rods and cones in the retina. Next the signal, much like electricity passing through a circuit, passes through the optic nerve, to the optic chiasm where it is split in half. Then in a microsecond the signal goes through the optic radiations to the occipital cortex in the back of the brain on both sides. So, light comes in the eye in front and is quickly sent to the occipital cortex in the back of the brain where it is perceived.
Spreading waves of depolarization are created in the occipital cortex in the migraine with aura sensitive brain which travel outward in concentric circles, much like the waves of water at a pond after one throws a rock in its surface. Neural tissue is made up on the cellular level by neurons which quickly fire off, or depolarize, as they release energy and then recharge
Spreading waves of depression from back to mid part of brain
Who discovered these spreading waves?
These spreading waves were discovered and written about by Aristides Leão[v] in 1944 in an article he published in the Journal of Neurophysiology.
Dr. Astride Leao
Originally, Leão intended to study "experimental epilepsy," specifically the propagation of electrically provoked seizure discharges in the cerebral cortex. To this end, he opened the skull of rabbits under anesthesia and arranged a row of chlorided silver wire electrodes in contact with the cortical surface.
Of these electrodes, one pair served for stimulation and the others, connected in six staggered pairs, for bipolar recording of the electrocorticogram (ECoG) at increasing distance from the stimulated points. Unexpectedly, instead of seizure-like discharge, the stimulation was frequently followed by a flattening of the spontaneous ECoG waves traced by the Grass oscillograph. The ECoG activity in the electrodes nearest to the stimulated area was silenced first, and then the extinction spread in orderly sequence from one electrode pair to the next, eventually covering almost all the cortex. Recovery of the ECoG waves occurred in the same sequence as their previous depression.
Leao’s EEG tracing showing decreased brain waves moving across cerebrum.
Patients report spots or holes or seeing half of things. Sometimes they see images with jagged borders bent in the shape of a large letter C. A spot or hole in the visual field is called a scotoma. They may have negative visual effects where they lose vision or positive visual effects where they see something like an image or streaks of light which are not a part of normal vision.
C-shaped zig-zag image.
The positive effects are noted with the eyes closed and many patients through the centuries have drawn pictures of what they have seen during their migraine experiences. I have some of these pictures in my office and show them to patients to see if they strike a chord and most of the time they do. “A picture says a thousand words.”
Usually I like the patient to draw what they see and they can almost always do this, sometimes quite well and with vivid detail, as if the images had been burned into their memory.
Is Migraine with aura a worse medical problem than migraine without aura?
Yes, 6% of migraine with aura patients may have a stroke. Stroke is increased by smoking and taking the birth control pill. These should be avoided in general and in migraine with aura patients in particular.
Summary
Migraine with aura is very different from migraine without aura because it has such prominent visual, numb and tingling limb and face symptoms, and trouble speaking. The comparison of the headache part between the two may be similar, or sometimes migraine with aura patients have milder headaches.
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Crescent scintillating migrainous aura
Bibliography
[i] The International Classification of Headache, 2nd Edition. Migraine with Aura. Cephalalgia 2004. 24; (Supplement 1): 25-27.
[ii] Classification of Headache. JAMA. 1962;179(March 3):717-718.
Aura
[iii] The International Classification of Headache, 2nd Edition. Typical aura without headache. Cephalalgia 2004. 24;(Supplement 1):28.
[iv] Lauritzen M. Cortical spreading depression as a putative migraine mechanism. Trends Neurosci, 1987;10:8-13.
[v] Leao AAP, Spreading depression of activity in the cerebral cortex. J Neurophysiol. 1944;7:359-390.
[vi] http://www.abc.org.br/academicos/fotos/aristides.jpg.
[vii] http://jn.physiology.org/cgi/content/full/94/1/2/F2.
[viii]http://images.google.com/imgres?imgurl=http://www.kopzorgen.nl/images/aura.jpg&imgrefurl=http://www.islamicboard.com/general/134283568-migraine-sufferers.html&usg=__LOuRUcyhj-CkImT6-KTntQxL64Q=&h=200&w=300&sz=20&hl=en&start=16&um=1&tbnid=O6sOa87e-NgCxM:&tbnh=77&tbnw=116&prev=/images%3Fq%3Dmigraine%2Bkopzorgen%26hl%3Den%26rlz%3D1C1CHMB_enUS345US345%26um%3D1
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All the best.
Britt Talley Daniel MD
