Migraine aura without headache: benign, but a diagnosis of exclusion

Migraine aura without headache should be considered as a diagnosis in anyone who has recurrent episodes of transient symptoms, especially those that are visual or neurological or involve vertigo. Visual and neurological symptoms due to migraine are not unusual and most commonly occur in older persons with a history of migraine headaches. Migraine aura without headache should be diagnosed only when transient ischemic attack and seizure disorders have been excluded.     

Intranasal lidocaine to prevent headache following migraine aura

OBJECTIVE: To report the consistent effect of intranasal lidocaine 4% on preventing headache following aura in one individual. BACKGROUND: A treatment that could prevent the headache which follows an aura would be an important advance in the treatment of migraine. No migraine abortive treatment has been shown to have such an effect. METHODS: A 15-year-old adolescent boy with a history of recurrent headache since aged 2, fulfilling the criteria for migraine with aura, was seen in consultation. Intranasal lidocaine 4% was used during the aura phase to prevent the headaches. RESULTS: Before using intranasal lidocaine, the patient invariably experienced a migraine following a typical visual aura. The episodes occurred approximately weekly, with a stable pattern for several years. When given during the aura, intranasal lidocaine prevented the headache following the aura, and remained successful on all but two occasions over 1 1/2 years of use (approximately 75 episodes). There was no effect on the duration of the aura itself. CONCLUSIONS: Intranasal lidocaine consistently prevented the development of headache symptoms following aura in this individual. Such an effect suggests a role for the sphenopalatine ganglion in the development of migraine pain.     

Exploding head syndrome followed by sleep paralysis: a rare migraine aura

A 26-year-old patient is described with a unique migraine aura. She described an 8-year history of episodes occurring 1 to 2 times yearly of exploding head syndrome followed by sleep paralysis followed by a migraine headache. She also had identical headaches without aura about once per week. Both aura symptoms, which may occur in the brainstem, resulted in activation of the trigeminovascular system through an unknown mechanism.     

IHS criteria and gender: a study on migraine and tension-type headache in children and adolescents

The aim of this study was to investigate whether the IHS criteria for migraine and tension-type headache depend on gender. Among 409 children and adolescents with recurrent idiopathic headache seen at a university outpatient clinic, girls had significantly more often migraine with aura. Also, there was a trend towards a higher frequency of tension-type headache in girls. In migraine, aggravation of headache by physical activity and occurrence of aura symptoms were more common in females, whereas vomiting and phonophobia occurred more often in males. In tension-type headache, females more often reported mild intensity of headache. All other criteria were similar in both sexes. Age influenced the expression of some of the accompanying symptoms in the various types of migraine, but had only minimal influence on other diagnostic criteria of migraine and tension-type headache in females as well as in males. Our study suggests that the frequency of migraine (except that of migraine with aura) is similar among girls and boys, that tension-type headache may occur more often in girls, and that gender has some influence on the IHS criteria for migraine, but almost no influence on those of tension-type headache.     

Improved description of the migraine aura by a diagnostic aura diary

We present a diagnostic aura diary for prospective recordings of migraine with aura. Three questionnaires are supplemented with sheets for drawings and plottings of visual and sensory auras. Twenty patients recorded 54 attacks of migraine with aura and 2 attacks of migraine aura without headache. The visual and sensory aura were usually gradually progressive, reaching maximum development in 15 and 25 min (median) respectively and had a total duration of 20 and 55 min (median) respectively. Approximately 13% of the attacks had acute onset of visual aura associated with other features more typical of migraine. The visual and sensory auras always preceded typical migraine headache, and headache occurring before aura symptoms was always of the tension type, The migraine headache was milder than in attacks of migraine without aura and often did not have migraine characteristics. In attacks with unilateral head pain, headache and aura symptoms were contralateral in 90% and ipsilateral in 10%.     

Recurrent Lilliputian hallucinations as visual aura symptom in migraine

Since her early 30s a 72-year-old female migraine sufferer has experienced recurrent episodes of Lilliputian hallucinations occurring at the peak of her severe migraine attacks and lasting between 2 min and 5 min, suggesting that her miniature hallucinations represent a visual migraine aura symptom. The existence of Lilliputian hallucinations of a migrainous nature is confirmed by four similar case reports reviewed from the migraine literature. The occurrence of similar Lilliputian hallucinations in the syndrome of peduncular hallucinosis, due to mesencephalic and/or thalamic lesions, supports the notion that the patient's recurrent Lilliputian hallucinations might have been aura symptoms of basilar migraine.     

Migraine postdromes: symptoms after attacks

To determine the nature and duration of symptoms after the headache phase of migraine, 40 migraineurs (11 with and 29 without an aura) were given a questionnaire to complete on the day after a migraine attack. The most common symptoms that remained were physical and mental tiredness, subdued or depressed mood, impaired concentration, reduced physical activities and yawning; weak or clumsy limbs, head tenderness, neck ache or stiffness, impaired sight and altered fluid balance were less frequent. The number of symptoms ranged from 2 to 11 (average 6) per patient lasting for a mean of 18 h, usually the whole of the next day. Symptoms after the main migraine attack can help to diagnose migraine particularly when there is no aura before the onset of headache. Eliciting postdromes aids patient-doctor rapport and confidence. The range of symptoms lends support to the notion that the whole of the brain is involved in the aftermath of migraine attacks.     

New onset migraine with aura following head injury: a case report

A patient is described who developed recurrent headaches following a traumatic injury in the vicinity of the right greater occipital nerve (GON) that fulfill IHS criteria for migraine with aura. Both aura and headache can be triggered by pressure over the GON and relieved by local anesthetic blockade.     

Migraine with persistent aura in a Mexican patient: case report and review of the literature

Persistent aura symptoms in patients with migraine are rare but well documented. The International Headache Society defines persistent aura without infarction as when the aura symptoms persist for > 1 week without radiographic evidence of infarction. The visual aura of migraine attacks has been explained by cortical spreading depression. We describe a case of a 28-year-old Mexican woman, who presented with persistent aura symptoms, and a literature review. The patient had a 24-year history of migraine headache. In November 2005 the patient had an attack which started with scintillating scotomas bilaterally associated with photopsias and amaurosis followed by migraine headache. All imaging studies were negative. The episode lasted 35 days and probably resolved with nimodipine therapy. Persistent aura symptoms are rare entities. This is the first case documented of a Mexican patient with persistent aura without infarction and probably resolved with nimodipine therapy.     

Prevalence of migraine in schoolchildren and some clinical comparisons between migraine with and without aura

OBJECTIVES: To determine the prevalence of migraine and its association with age, gender, and social class and to find out whether or not the headache and nonheadache characteristics differ between children with migraine, with and without aura, using the diagnostic criteria of the International Headache Society for childhood migraine. DESIGN: Population-based study in two stages comprising an initial screening questionnaire followed by telephone interviews of children with symptoms. SETTING: Eighteen kindergarten and 39 primary and secondary schools in Thessaloniki and its semiurban areas. SUBJECTS: Four thousand children, aged 4 to 15 years, representing a random sample of 5% of schoolchildren in Thessaloniki and its semiurban areas. MAIN OUTCOME MEASURES: (1) The prevalence of migraine, (2) the connection of migraine with social class, (3) differences in the occurrence of individual symptoms between migraine with and without aura. RESULTS: The results of the present study show that migraine prevalence was 6.2% (95% confidence interval [CI], 5.4 to 7.0). The estimated prevalences of migraine with and without aura were 2.8% (95% CI, 2.3 to 3.4) and 3.4% (CI, 2.8 to 4.0), respectively. The prevalence of migraine increased with age and it was found to be almost equal in boys and girls aged 7 to 9 years or younger, but in older age groups the prevalence was higher in girls than in boys. The data showed no evidence that connected migraine with social class. It also showed that except for the aura, the headache (e.g., frequency, duration, location, quality, and severity) and nonheadache (e.g., nausea, vomiting, phonophobia, and photophobia) characteristics were no different between children with migraine, with and without aura. In conclusion, our findings indicate that migraine is a common underdiagnosed cause of severe recurrent headache in children. The findings show that childhood migraine is not connected with social class and varies with age and gender, and that except for the aura, both migraine with and without aura are so similar in their headache and nonheadache clinical characteristics that a common pathogenesis is plausible.     

Occipital Lobe Tumor Presenting as Migraine With Typical Aura

We report the case of a 60-year-old woman in whom migraine with typical aura heralded the presence of an occipital lobe tumor. Her headache was characterized by recurrent episodes of visual aura confined to the left visual field followed by right hemicranial throbbing headaches accompanied by nausea, photophobia, and phonophobia. Interictal neurologic and ophthalmologic examinations were negative, as was an unenhanced brain CT scan. The headaches increased in frequency over 4 months despite a number of medications known to prevent attacks of migraine.
A low-grade right occipital lobe tumor was eventually discovered on MR scan. This case illustrates that headache fulfilling the International Headache Society (IHS) criteria for migraine with typical aura can occur in association with an occipital lobe tumor.     

Headache Diary in the Diagnosis of Childhood Migraine

The usefulness of a headache diary in the diagnosis of migraine and in the clarification of migraine symptoms was studied in 145 children. These children belong to a 1year age cohort of 5356 children that has been followed since birth. The children were enrolled in the present study according to their headache status in a questionnaire study at the age of 8 to 9 years, at which time 50 children had migraine, 43 had nonmigrainous headache, and 52 did not have recurrent headache. Information on their present headache status was collected with a face-to-face interview at the age of 11 to 13 years and from a headache diary after the interview. The children kept the diary for 2 to 7 months. Altogether, 72 children had migraine according to the International Headache Society criteria for migraine, either in the interview or in the diary. Eight children were diagnosed only according to the diary (11.1%). Thirty-three children had both migraine attacks and nonmigrainous headache episodes according to the diary, even though they were able to report only one type of headache episode in the interview. The duration of headache episodes was underestimated in the interview, compared to the diary in the children with migraine. Many children recognized new aura symptoms, associated symptoms, and characteristics of pain when they started to pay attention to these when filling in the diary during the follow-up period. The headache diary is useful in clarifying the features of headache attacks and in the diagnosis of headache types in children.     

Preventing disturbing migraine aura with lamotrigine: an open study

BACKGROUND: Lamotrigine has been suggested as possibly effective for preventing migraine aura. OBJECTIVE: To describe our experience with a series of patients with disturbing migraine aura treated with lamotrigine. METHODS: The members of the Headache Group of the Spanish Society of Neurology were sent an ad hoc questionnaire to collect patients treated with lamotrigine due to disturbing migraine aura. The main outcome parameter ("response") was a >50% reduction in the mean frequency of migraine auras at 3 to 6 months of treatment. RESULTS: A total of 47 patients had been treated with lamotrigine due to severe migraine aura. Three could not complete the protocol as a result of developing skin rashes. Thirty (68%) patients responded. These were 21 females and 9 males whose ages ranged from 19 to 71 years. Eight suffered from migraine with "prolonged" aura, 8 typical aura with migraine headache (but had frequent episodes including speech symptoms), 6 basilar-type migraine, 6 typical aura without headache, and 2 hemiplegic migraine. Fifteen had been previously treated, without response, with other preventatives. The mean monthly frequency of migraine auras in these 30 patients changed from 4.2 (range: 1 to 15) to 0.7 (range: 0 to 6). Response was considered as excellent (>75% reduction) in 21 cases (70% of responders). Auras reappeared in 2 months in 9 out of 13 patients where lamotrigine was stopped, and ceased as soon as this drug was reintroduced. CONCLUSIONS: Lamotrigine should be considered in clinical practice for the preventive treatment of selected patients with disturbing migraine auras. Lamotrigine seems worthy of a controlled trial as prophylaxis of migraine aura.     

Effect of age on the fulfilment of the IHS criteria for migraine in children at a headache clinic

In a headache clinic, 247 children suffering from severe recurrent headaches were studied in relation to the IHS criteria for migraine. Of the 247, 163 had migrainous headache, with 110 (67.5%) of these having migraine in accordance with the IHS criteria. The remaining 53 (32.5%) had headache attacks fulfilling all but one of the IHS criteria. Coverage of the IHS criteria for migraine was 93%. Symptoms of unilateral headache, aggravation by physical activity, and nausea showed the greatest differences in frequency between those with migraine and those with probable migraine. All children with aura fulfilled criteria for migraine. Children with migraine with aura (11.8, 95% CI: 11.0–12.6 years) were older than those without aura (10.1, 9.4–10.8 years; p = 0.001). Children with pulsating headache were slightly older than children without pulsating headache. No differences in age were detected for the other IHS criteria.     

Retinal migraine

Retinal migraine is a primary headache disorder, clinically manifested by attacks of transient monocular visual loss associated with migraine headache. Although isolated reports suggest that retinal migraine is rare, it likely is under-recognized. Retinal migraine usually is reported in women of childbearing age who have a history of migraine with aura. It typically is characterized by negative monocular visual phenomena lasting less than 1 hour. More than half of reported cases with recurrent transient monocular visual loss subsequently experienced permanent monocular visual loss. Although the International Headache Society diagnostic criteria for retinal migraine require reversible visual loss, our findings suggest that irreversible visual loss is part of the retinal migraine spectrum, likely representing an ocular form of migrainous infarction.     

Familial hemiplegic migraine presenting as recurrent encephalopathy in a Native Indian family

BACKGROUND: Familial hemiplegic migraine (FHM) is an autosomal dominant disorder, which can result from mutations in the CACNA1A (FHM1) and ATP1A2 (FHM2) genes. Typically, FHM presents with an aura of hemiplegia accompanied by a moderate-to-severe headache. FHM can be associated with other neurological findings including coma and seizures. METHODS: We describe the clinical and genetic features of a two-generation, seven-member Native Indian family with recurrent encephalopathy and FHM. RESULTS: Two of the three affected family members presented initially with encephalopathy, the third family member presented with classic episodes of migraine and hemiparesis. The CACNA1A gene locus was excluded in this family by haplotype analysis and no mutations were identified in the coding region of the ATP1A2 gene by direct sequencing. CONCLUSIONS: This emphasizes the genetic and clinical heterogeneity in familial hemiplagic migraine FHM and highlights the need to consider the diagnosis of FHM in cases of recurrent encephalopathy.     

Clinical characteristics of 362 patients with familial migraine with aura

The objectives of the present study were to describe the clinical characteristics of patients with severe familial non-hemiplegic migraine with aura (NHMA) and to compare these data to those from cases in previous population-based Danish studies using the same methodology. NHMA families were recruited from the Danish patient registry and from Danish neurology practices. A total of 362 NHMA patients were diagnosed according to the 1988 International Headache Society criteria using a validated semistructured physician-conducted interview. Visual aura occurred in almost every NHMA attack. In aura without headache visual aura occurred primarily in isolation. Aura without headache was most common in older, male patients. Several clinical characteristics of familial NHMA differed from migraine with aura in the general population: firstly, the age at onset was lower, secondly, the age at cessation was higher, thirdly, aura symptoms were more severe and finally, the co-occurrence of migraine without aura was higher in familial NHMA. There seems to be a correlation between more severe symptoms and familial aggregation. These results have both clinical and scientific implications.     

Headache Spectrum in Arnold-Chiari Malformation

Exertional headaches in patients with Arnold-Chiari malformation (ACM) are well described. We report four patients with Type I ACM and recurrent headaches. These patients presented, respectively, with low spinal fluid pressure headache, migraine without aura, migraine with aura, and migraine with prolonged aura. This report suggests the need for observing patients with recurrent headaches for any physical stigmata of craniovertebral junction anomalies, and the need to exclude ACM in such patients. Possible implications of the association between ACM and different types of headaches are discussed.     

Visual aura in ice cream headache

Abstract We present a case of cold-induced visual symptoms in a 74-year-old woman with a history of migraine headaches. Migraine without aura was the starting symptom. It coexisted later with a typical pain of ice cream or cold stimulus headache that persisted after the migraine vanished. Finally the headache disappeared and the course was characterised by episodes of pure visual symptoms, always after swallowing cold material. The vasodynamic effects underlying migraine are invoked to understand this case, but the activation of the trigeminal system provides a better explanation for the symptoms of this patient. Thus trigeminal activated headache and aura could include a subform like this one, characterised by pure hemianopsia after ingesting cold material.