Migrainous Prolonged and Reversible Bilateral Inferior Altitudinal Visual Field Defect

Migrainous patients may have visual field deficits at times between migraine attacks that mostly are unilateral and resolve after 7-10 days. Herein, we report a 25-year-old woman, a known case of classic migraine, with bilateral inferior altitudinal visual field defect and complete recovery after 4 months. All lab tests, including brain magnetic resolution imaging and angiography, coagulation tests and visual evoked potentials, were normal.     

Migrainous complex hallucinations in a 17-year-old adolescent

Olfactory hallucinations have been reported in association with numerous neurological and psychiatric disorders, in particular as a component of partial complex seizure and psychiatric disorders, but are rarely described in migraine disease. We report the case of an adolescent who reported complex hallucinations during a migraine attack.     

Transient visual disturbances during migraine without aura attacks

OBJECTIVE: To evaluate the prevalence and clinical features of transient visual disturbances (TVDs) during migraine without aura (MO) attacks and to point out any similarities with the disturbances listed among the diagnostic criteria of the International Headache Society (IHS) classification for migraine with aura (MA). METHODS: We studied a sample of 191 patients (145 women and 46 men) with MO and no other associated forms of primary headache who had been referred to the University of Parma Headache Centre between December 1, 1999 and December 1, 2000. RESULTS: A total of 165 patients reported that they had never experienced TVDs during their MO attacks. In the remaining 26 patients (19 women and 7 men), MO attacks were at times accompanied by TVDs, which were present in over 30% of MO attacks in 65.4% of patients. In about 60% of cases, TVDs lasted less than half a minute. TVDs consisted of phosphenes in most patients, general blurring of vision in about one-fourth, and scintillating scotomas in 15%. In 73% of cases, TVDs occurred during the headache phase, whereas in the remainder they preceded it. Strict application of the IHS diagnostic criteria would have led to a diagnosis of MA in 12 cases, corresponding to 46% of our MO patients with TVDs and to 6.3% of all patients with an established clinical diagnosis of MO. CONCLUSION: The results of our study suggest that current IHS diagnostic criteria for MA may lead to an overestimation of MA cases.     

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.     

Migrainous aura versus transient ischemic attack in an elderly migraineur

In older patients with migraine, the distinction between a migrainous aura and a transient ischemic episode can be difficult, as this case illustrates.     

Simultaneous recording of pattern reversal electroretinograms and visual evoked potentials in migraine

We recorded full-field pattern seversal electroretinograms (PERGs) and visual evoked potentials (PVEPs) simultaneously in 15 migraine with aura, 14 migraine without aura patients during the interictal period, and in 23 sex- and age-matched normal subjects. All subjects had normal visual fields. The visual aura in all patients was hemianopsia or fortification spectra. Neither migraine group showed significant differences from normal in latency and amplitude of PERGs. In migraine with aura, the amplitudes of PVEPs in classic migraine at the mid-occipital electrode were significantly ( p <0.01) higher than normal. PVEP amplitudes were significantly ( p <0.01) high or on the contralateral side of the aura than the ipsilateral side in both visual aura and normal subjects, but there was no significant difference in latency. This high amplitude and asymmetry of PVEPs may contribute to defective inhibition between interhemispheric visual occipital areas or striate and peristriate areas.     

Characteristics of Migraine Visual Aura

Visual auras (VAs) of 100 patients with migraine with aura were studied by questionnaire. Visual auras accompanied the patients' first headache (HA) in 39% of patients. Only 19% had VAs with every attack. Patients with VAs over the entire HA history had a high frequency (greater than 50%) of attacks with VA; patients with VA during only part of the HA history had a low frequency (less than 50%} of attacks with VA. The auras occurred exclusively prior to the HA in 57%. The free interval between the end of the VA and the start of the HA was usually (75%) shorter than 30 minutes. Most (59%) patients had VAs that lasted from 1 to 30 minutes. They started in the periphery of the visual fields in 56%. The most common phenomena described were: small bright dots (42%), flashes of light (39%), "blind spots" (32%), and "foggy vision" (27%). Fortification spectra was reported by only 20%. Although most (65%) patients had a combination of phenomena, the majority (72%) had only one uniform constellation of manifestations. There was no clear-cut relationship between side of VA and side of HA.
Migraine VA is a pleomorphic and complex symptom. Many patients not qualifying for the diagnostic criteria of migraine with aura, as proposed by the International Headache Society (IHS) unequivocally present with visual phenomena that strongly suggest this diagnosis.     

Persistent and Repetitive Visual Disturbances in Migraine: A Review

Visual disturbances in migraineurs, such as visual aura, are typically episodic, that is, associated with the headache attack, and overlaid by head pain and other symptoms that impact the patient. In some patients, however, visual symptoms are dominant due to frequency (migraine aura status), duration (persistent migraine aura and other persistent positive visual phenomena), or complexity (visual snow syndrome). These syndromes are more rare and challenging to classify in clinical practice resulting in a lack of systematic studies on pathophysiology and treatment. We aim at describing clinical features and pathophysiological concepts of typical migraine aura with a focus on cortical spreading depression and differentiation from non‐typical migraine aura. Additionally, we discuss nomenclature and the specifics of migraine aura status, persistent migraine aura, persistent positive visual phenomena, visual snow, and other migrainous visual disturbances. The term migraine with prolonged aura might be a useful bridge between typical aura and persistent aura. Further studies would be necessary to assess whether a return of the classification category eventually helps diagnosing or treating patients more effectively. A practical approach is presented to help the treating physician to assign the correct diagnosis and to choose a medication for treatment that has been successful in case reports of these rare but disabling conditions.     

Pattern reversal visual evoked potentials in migraine with aura and migraine aura without headache

Pattern reversal visual evoked potentials (PVEPs) were recorded in 20 patients with migraine with aura (MA), 19 patients with migraine without headache (migraine equivalent; ME.) during interictal periods, and 34 normal subjects. All migraine patients had hemianopsia or fortification spectra during attacks. In both MA and ME patients of less than 49 years of age, there were significant ( p <0.01) differences in amplitude of PVEPs at the mid-occipital and contralateral to visual aura electrode sites compared to normal subjects. Amplitude of PVEPs in MA and ME showed significant ( p <0.001) increases when recorded soon after attacks, especially within 10 days. There was a significant ( p <0.0l) correlation between percentage asymmetries and the duration of illness in both MA and ME. We conclude from our PVEP findings that cortical spreading depression remains the most likely explanation for the migraine visual aura.     

Migraine with aura and reproductive life events: a case control study

The course of migraine without aura (MO) is greatly influenced by the events of female reproductive life. Much less is known about migraine with aura (MA). The aim of this study was to evaluate the relationship between MA and the milestones of reproductive life. A retrospective case control study was carried out on 100 women affected by migraine with typical aura (cases) and 200 age-matched women with MO (controls). Premenstrual syndrome was found to be much more common among the patients with MA (odds ratio (OR) 6.0; confidence interval (CI) 3.1-11.6). Menstrually triggered migraine was more frequently encountered among MO than among MA patients (MA 15.0%; MO 53.5%; OR 0.1; CI 0.1-0.3). In both forms of migraine, pregnancy had a favourable effect; however, a lower percentage of MA (43.6%) than MO patients (76.8%; OR 0.2; CI 0.1-0.5) showed improvement or remission. The use of oral contraceptives worsened migraine in MA more frequently than in MO patients (MA 56.4%; MO 25.3%; OR 3.8; CI 1.6-9.3). The course of MA seems to be influenced by female reproductive life events, but in a different way with respect to MO.     

Cerebrovascular response to repetitive visual stimulation in interictal migraine with aura

Cortical hypersensitivity and absent habituation to different stimuli have been observed in migraine patients. These features might also be transmitted to the cerebral vasoreactivity, but results are conflicting so far. Transcranial Doppler ultrasound (TCD) was used to assess cerebral blood flow velocity (CBFV) changes in the middle (MCA) and posterior cerebral arteries (PCA) in relation to repetitive checkerboard visual stimulation. Stimulation consisted of 10 consecutive cycles, each comprising 10 s stimulation and 10 s rest. TCD recordings were analysed using stimulus-related averaging algorithm. Data of 19 interictal migraineurs with aura were compared to those of 19 headache-free healthy volunteers. The CBFV increase in PCA and in MCA during visual stimulation was significantly larger and steeper in migraineurs than in controls (P = 0.017 and P = 0.005). The response in PCA remained stable over the 10 stimulation cycles, both in migraineurs and in controls. The response in MCA was stable only in migraineurs. In controls it decreased over the last 5 stimulation cycles compared with the first 5 cycles (P = 0.04). Migraineurs with aura exhibit a larger cerebrovascular response to repetitive visual stimulation compared to headache-free subjects. A reduced adaptation to environmental stimuli in migraine is suggested, since there was no habituation in migraineurs in contrast to healthy controls.     

Cognitive processing in migraine: a failure to find facilitation in patients with aura

Recent interest in cognitive processing in migraine has been based on the assumption that cortical hyperexcitability in migraine with aura may manifest itself in the form of response time advantages in migraine as compared to controls. The study reported here attempted to replicate and extend the findings of Wray and colleagues (Brain 1995;118:25–35). Using identical cognitive tasks, three experiments failed to find differences between migraine with aura patients and controls: furthermore, an additional group of patients without aura were also statistically indistinguishable from controls with respect to response times. Error rates were consistently high across experiments, indicating that subjects were responding at or near chance levels. These findings cast doubt on the utility of straightforward cognitive psychological methods for the study of cortical hyperexcitability in migraine. Some theoretical difficulties concerning the interpretation of response times in the context of migraine pathophysiology are discussed.     

Diffusion- and perfusion-weighted MR imaging in persistent migrainous visual disturbances

Pathological changes on diffusion-weighted MR scans had been described in hemiplegic migraine and perfusion changes had been demonstrated in typical migraine aura with radio-isotope studies and, more recently, MR perfusion imaging. However, there is relatively little knowledge of the pathophysiology of long-lasting migraine aura and its possibly variant phenotype, visual snow. Our aim was to investigate with advanced MR techniques whether patients with long-lasting visual disturbance showed regional alterations in cerebral water diffusion and perfusion. We have studied four patients using MR perfusion and MR diffusion imaging. Two patients had typical visual aura and two had a primary persistent visual disturbance (visual snow phenomenon). All patients had normal conventional structural MR imaging. MR diffusion-weighted images were acquired with a b-value of up to 1000 s/mm2. From the diffusion weighted images we generated maps of apparent diffusion coefficient (ADC), which were inspected visually and used for ADC measurements of predefined regions of interest, which included the visual, frontal, insular and temporal cortices. MR perfusion imaging was performed using a bolus tracking technique with dynamic susceptibility-weighted images. Colour coded maps of relative cerebral blood volume, mean transit time and bolus arrival time were generated, as well as time-signal intensity curves over the anterior, middle and posterior cerebral artery territories. The maps of the ADC and above perfusion parameters appeared symmetrical in all patients with no evidence of decreased water diffusion or cerebral perfusion in the occipital regions, or elsewhere. There was no statistically significant difference between the ADC measurements of the primary visual cortices and other cortical regions. Our findings suggest that regional changes in cerebral water diffusion and perfusion do not play an important part in the pathophysiology of persistent migraine aura or primary persistent visual disturbance.     

Brain Apparent Water Diffusion Coefficient Magnetic Resonance Image During a Prolonged Visual Aura

(Headache 2010;50:1045‐1049) Background.— Reversible changes in brain magnetic resonance imaging (MRI) weighted in diffusion‐weighted images (DWI) and apparent water diffusion coefficient (ADC) maps have been reported in acute stroke, epilepsy, eclampsia, and hypoglycemia, but they are contradictory regarding to migraine aura. Objective.— A 41‐year‐old woman with known basilar migraine for 5 years consulted about a persistent visual aura (visual snow phenomenon) plus bilateral paresthesias in the extremities for 4 days. The headache was treated with success with 10 mg of wafer rizatriptan and 600 mg of ibuprophen. Methods.— The neurologic and ophthalmologic examination were normal. An urgent brain MRI detected no lesions in T1, T2, fluid‐attenuated inversion recovery, and DWI, but an abnormal signal appeared in the left occipital lobe in ADC and (r)ADC maps. The brain MRI angiography, carotid ultrasound study, transesophageal echocardiography, 24‐hour cardiac Holter monitoring, and thrombophilia study were normal. Results.— A new brain MRI 8 days after did not show any previous lesion in the same sequences. Conclusions.— We present a patient with migraine and transitory abnormal signals in the ADC map of an occipital region during persistent visual aura. The clinical‐radiological relationship is congruent. Some similar cases have showed these MRI signals during the aura, suggesting cytotoxic edema, without ischemic lesions in the MRI controls. Theses ADC images probably appear in complex auras.     

Early treatment of migraine with rizatriptan: a placebo-controlled study

OBJECTIVE: To evaluate the efficacy of rizatriptan when administered early during a migraine attack. BACKGROUND: Several studies indicate that triptans are more efficacious when administered early during a migraine attack, when the pain is still mild. METHODS: One hundred and twelve rizatriptan-na?ve patients aged 20 to 64 years with a history of migraine with or without aura that progressively worsened when left untreated were instructed to treat a total of three migraine attacks with either rizatriptan 10 mg or placebo as early as possible during each attack. Seventy-four patients (68 women and 6 men) were assigned to use the active drug and 38 (35 women and 3 men) to placebo. The primary efficacy endpoint was pain-free response at 2 hours after administration of the study drug. Secondary efficacy measures were pain-free response at 1 hour and sustained pain-free response lasting between 2 and 24 hours. RESULTS: A total of 216 attacks were treated in the rizatriptan group and 109 in the placebo group. Pain-free response at 2 hours after early treatment was noted in 151 (70%) of attacks in the rizatriptan group and in 24 (22%) in the placebo group (P < .01). Pain-free response at 1 hour occurred in 97 (45%) and 9 (8%) attacks, respectively (P < .01). When the attacks were categorized by headache severity at the time of treatment, the pain-free response at 2 hours was higher for mild attacks than for moderate or severe attacks (P < .01). Sustained pain-free response after treatment was significantly higher for attacks treated with rizatriptan (60%) than for those treated with placebo (17%) (P < .001). Adverse events were observed in 62 patients in the rizatriptan group and 15 in the placebo group. Only 1 patient taking rizatriptan discontinued the study because of adverse events, and no serious adverse events were reported. CONCLUSIONS: Rizatriptan is significantly more likely than placebo to produce a pain-free response within 2 hours when the drug is administered early in the migraine attack, when pain is mild rather than moderate or severe.