Headache and ischemic stroke

Migraine is a common neurological condition affecting yearly 1%–10% of all men and 3%–20% of all women. Focal neurological symptoms (auras), most commonly visual and sensory, occur in 4% of migraine attacks. Migraine with and without aura seems to be associated with an increased stroke risk. Migraine with aura may mimic transient ischemic attacks and may induce stroke (migrainous stroke). Headache is also a common symptom during ischemic stroke In this review, we present the evidence about each of these circumstances to better understand the relationship between headache, especially migraine, and ischemic stroke. Received: 27 September 2001 / Accepted in revised form: 27 December 2001     

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%.     

Migraine variants

The term "migrant variant" is not used in the headache classification of the International Headache Society (IHS), but it includes those forms of migraine that are not typical of migraine with or without aura. Headaches that do not quite fulfill all of the IHS criteria are termed "migrainous disorder." Migraine associated with auras arising from unusual sites includes basilar migraine, retinal migraine, and ophthalmoplegic migraine. Two of the chromosomal sites for hemiplegic migraine have been identified. Migraine aura may occur without headache and an aura may be prolonged. Migrainous infarct has occurred when the aura lasts more than 1 week or imaging studies are positive and other etiologies have been ruled out. If the migraine attack is prolonged beyond 3 days the term "status migrainousus" is applied.     

Pure menstrual migraine with sensory aura: a case report

Hormonal changes related to the menstrual cycle have a great impact on migraines in women. Menstrual migraine attacks are almost invariably without aura. Categorizing migraines into menstrual or non-menstrual types is one way to stratify migraines without aura according to the appendix criteria of the International Classification of Headache Disorders. We report a peri-menopausal woman whose sensory aura exclusively heralded menstrual migraine. A 51-year-old woman had suffered from monthly episodic headaches since the age of 46. Before a headache, and within 1?h on the first day of her menstruation, she always experienced numbness in her entire left upper limb. After the sensory aura, migrainous headaches occurred with nausea and photophobia. In the postmenopausal period, she no longer had sensory aura, and her headache pattern changed and became less severe. Her physical and neurologic exams as well as electroencephalography, brain magnetic resonance imaging, and conventional angiography were all normal. She fulfilled the diagnosis of pure menstrual migraine with typical sensory aura. To our knowledge, this is the first formal case report of pure menstrual migraine with aura.     

Association of benign recurrent vertigo and migraine in 208 patients

The aim of this study was to determine the association of benign recurrent vertigo (BRV) and migraine, using standardized questionnaire-based interview of 208 patients with BRV recruited through a University Neurotology clinic. Of 208 patients with BRV, 180 (87%) met the International Classification of Headache Disorders 2004 criteria for migraine: 112 migraine with aura (62%) and 68 without aura (38%). Twenty-eight (13%) did not meet criteria for migraine. Among patients with migraine, 70% experienced headache, one or more auras, photophobia, or auditory symptoms with some or all of their vertigo attacks, meeting the criteria for definite migrainous vertigo. Thirty per cent never experienced migraine symptoms concurrent with vertigo attacks. These met criteria for probable migrainous vertigo. Among patients without migraine, 21% experienced either photophobia or auditory symptoms with some or all of their vertigo attacks; 79% experienced only isolated vertigo. The age of onset and duration of vertigo attacks did not differ significantly between patients with (34 ± 1.2 years) and patients without migraine (31 ± 3.0 years). In patients with migraine, the age of onset of migraine headache preceded the onset of vertigo attacks by an average of 14 years and aura preceded vertigo by 8 years. The most frequent duration of vertigo attacks was between 1 h and 1 day. Benign recurrent vertigo is highly associated with migraine, but a high proportion of patients with BRV and migraine never have migraine symptoms during their vertigo attacks. Other features such as age of onset and duration of vertigo are similar between patients with or without migraine.     

Aura phenomena do not initiate migraine attacks—Findings from neuroimaging

Objectives/Background

As cortical spreading depolarization (CSD) has been suggested to be the cause of migraine aura and as CSD can activate trigeminal nociceptive neurons in animals, it has been suggested that CSD may be the cause of migraine attacks. This raises the question of how migraine pain is generated in migraine attacks without aura and has led to the hypothesis that CSD may also occur in subcortical regions in the form of “silent” CSDs, and accordingly “silent auras”.

Methods

In this case study, we provide evidence for common neuronal alterations preceding headache attacks with and without aura in a male patient with migraine, who underwent daily event-correlated functional magnetic resonance imaging of trigeminal nociception for a period of 30 days. During these days the man experienced migraine attacks with and without aura.

Results

Comparing the preictal phases between both attack types revealed a common hyperactivation of the hypothalamus (p < 0.01), which was already present 2 days before the actual attack.

Conclusion

The time frame of the central pathophysiological orchestration of migraine attacks, irrelevant of the presence of later aura, strongly suggests that the aura is an epiphenomenon that is unrelated and does not initiate headache attacks.     

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.     

Are cortical spreading depression and headache in migraine causally linked?

During the past few decades, much controversy has surrounded the pathophysiology of migraine. Cortical spreading depression (CSD) is widely accepted as the neuronal process underlying visual auras. It has been proposed that CSD can also cause the headaches, at least in migraine with aura. We describe three patients, each fulfilling the International Headache Society criteria for migraine with aura, who suffered from headaches 6–10 days per month. Two patients were treated with flunarizine and the third patient with topiramate for the duration of 4 months. All patients reported that aura symptoms resolved completely, whereas the migraine headache attacks persisted or even increased. These observations question the theory that CSD (silent or not) is a prerequisite for migraine headaches.     

Specific Headache Phenomena: Their Frequency and Coincidence

The correlation of specific headache attack characteristics derived from a standardized questionnaire was studied in a consecutive series of 392 patients attending a headache clinic. In patients reporting headache with aura such attacks tended to be infrequent, and the percentage of their headache attacks that were preceded by aura varied widely, many cases having very low percentages. Paresthesias as auras were uncommon and rarely occurred without visual aura. Unilateral headaches were associated with nausea to widely varying degrees. Most patients reported both unilateral headache and headache with tension characteristics. Definite history of hypertension was significantly correlated specifically with migraine with aura (classic migraine).     

Pharmacokinetics and Pharmacodynamics of Avitriptan in Patients With Migraine After Oral Dosing

Avitriptan (BMS-180048) is a 5-HT₁-like receptor agonist for the treatment of migraine. This double-blind, placebo-controlled, randomized, parallel-group study evaluated the pharmacokinetics, safety, and preliminary efficacy of avitriptan in patients with migraine during migrainous and pain-free states. Patients met the IHS criteria for migraine with or without aura and suffered one to six migraines per month for at least 1 year. Patients in a clinic experiencing a migraine headache received avitriptan 75 mg, 150 mg, or 200 mg or matching placebo capsules. Blood samples were obtained before and 0.25, 0.5, 0.75, 1, 1.5, 2, 2.5, 3, 4, 5, and 6 hours after dosing. Headache intensity was rated before and up to 6 hours after dosing. Seven to 30 days after the inclinic treatment, patients returned in a pain-free state for the same study medication. All pharmacokinetic and safety measures were repeated. Forty-eight patients (9 men and 39 women) participated. Peak plasma concentrations of avitriptan were achieved 1 to 2 hours following dosing in migraine and pain-free states for all doses. The pharmacokinetics of avitriptan were proportional to dose during a migraine attack over the 75- to 200-mg dose range. The 150- and 200-mg doses of avitriptan demonstrated a greater decrease in headache intensity scores at 2 hours postdose. The most common adverse event was paresthesia. Thus, avitriptan was rapidly absorbed, well tolerated, and demonstrated preliminary efficacy in this population.     

Epidemiology of migraine among students from randomly selected secondary schools in Lodz

The purpose of the present study was to determine the prevalence of migraine among 2351 secondary school students aged 15 to 19 years. Six hundred fifty-nine students (120 males and 539 females) complained of migraine, including 148 with additional tension-type headache (mixed headache). Migraine with aura was diagnosed in 213 students (49 with mixed headache). The remaining 446 students (99 with mixed headache) had migraine without aura. In 83 students (16 with mixed headache), headaches were developing into migrainous states. In 237 students (56 with mixed headache), headaches were accompanied by dizziness. In 128 females (25 with mixed headache), interrelation between migraine and menstruation was found. Familial factors affecting the occurrence of migraine were noted in 536 students (127 with mixed headache). It was found that 28% of secondary school students aged 15 to 19 years suffer from migraine. Nine percent of them have migraine with aura and 19%, migraine without aura. The prevalence of migraine among secondary school students is about three times higher in females than in males. Migraine with tension-type headache differs from pure migraine in respect of more numerous attacks within 1 year among females, and of more frequent occurrence of migraine with sensory aura among males.     

Migrainous Infarction in a Patient With Sporadic Hemiplegic Migraine and Cystic Fibrosis: A 99mTc-HMPAO Brain SPECT Study

Genetic mutations of sporadic hemiplegic migraine (SHM) are mostly unknown. SHM pathophysiology relies on cortical spreading depression (CSD), which might be responsible for ischemic brain infarction. Cystic fibrosis (CF) is caused by a monogenic mutation of the chlorine transmembrane conductance regulator (CFTR), possibly altering brain excitability. We describe the case of a patient with CF, who had a migrainous stroke during an SHM attack. A 32-year-old Caucasian male was diagnosed with CF, with heterozygotic delta F508/unknown CFTR mutation. The patient experiences bouts of coughing sometimes triggering SHM attacks with visual phosphenes, aphasia, right-sided paresthesia, and hemiparesis. He had a 48-hour hemiparesis triggered by a bout of coughing with hemoptysis, loss of consciousness, and severe hypoxia-hypercapnia. MRI demonstrated transient diffusion hyperintensity in the left frontal-parietal-occipital regions resulting in a permanent infarction in the primary motor area. Later, a brain perfusion SPECT showed persistent diffuse hypoperfusion in the territories involved in diffusion-weighted imaging alteration. Migrainous infarction, depending on the co-occurrence of 2 strictly related phenomena, CSD and hypoxia, appears to be the most plausible explanation. Brain SPECT hypoperfusion suggests a more extensive permanent neuronal loss in territories affected by aura. CF may be then a risk factor for hemiplegic migraine and stroke since bouts of coughing can facilitate brain hypoxia, triggering auras.     

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.     

Migraine With Aura as the Presentation of Leukemia

We present the case of a man with new onset of migraine with aura as the presenting sign of acute promyelocytic leukemia and disseminated intravascular coagulation. This previously unreported association may support theories of platelet serotonin involvement in the pathogenesis of migraine. It would be valuable in the future to evaluate other patients with disseminated intravascular coagulation or acute promyelocytic leukemia for the presence of migrainous auras or headaches, symptoms which may be underreported by patients, particularly in the setting of severe illness.     

Retinal migraine reappraised

Retinal migraine is usually characterized by attacks of fully reversible monocular visual loss associated with migraine headache. Herein we summarize the clinical features and prognosis of 46 patients (six new cases and 40 from the literature) with retinal migraine based upon the International Classification of Headache Disorders-2 (ICHD-2) criteria. In our review, retinal migraine is most common in women in the second to third decade of life. Contrary to ICHD-2 criteria, most have a history of migraine with aura. In the typical attack monocular visual features consist of partial or complete visual loss lasting <1 h, ipsilateral to the headache. Nearly half of reported cases with recurrent transient monocular visual loss subsequently experienced permanent monocular visual loss. Although the ICHD-2 diagnostic criteria for retinal migraine require reversible visual loss, our findings suggest that irreversible visual loss is part of the retinal migraine spectrum, perhaps representing an ocular form of migrainous infarction. Based on this observation, the authors recommend migraine prophylactic treatment in an attempt to prevent permanent visual loss, even if attacks are infrequent. We also propose a revision to the ICHD-2 diagnostic criteria for retinal migraine.     

Migrainous disorder and its relation to migraine without aura and migraine with aura. A genetic epidemiological study

Migrainous disorder was analysed in a large population-based study of 4000 forty-year-old males and females. All interviews were conducted by one physician and the diagnostic criteria of the International Headache Society were used. Of the 48 people with migrainous disorder, 40 had migrainous disorder without aura and 9 had migrainous disorder with aura One person had co-occurrence of migrainous disorder with and without aura. The lifetime prevalence of migrainous disorder was 2.5% with a male: female ratio of 1:1.2. The first-degree relatives of probands with migrainous disorder were blindly interviewed. Compared with the general population, first-degree relatives of probands with migrainous disorder without aura had a slightly but less increased risk of migraine without aura than first-degree relatives of probands with migraine without aura. First-degree relatives of probands with migrainous disorder with aura had no increased risk of migraine with aura. We conclude that migrainous disorder without aura in some people is a type of migraine without aura and in other people not. Migrainous disorder with aura may be unrelated to migraine with aura.     

Migraine without aura and migrainous disorder in children; International Headache Society (IHS) and revised IHS criteria

The widely used criteria of the IHS to define migraine without aura in children are highly specific but show poor sensitivity, with a large percentage of headaches being classified as migrainous disorder (MD). The objective of this study was to assess how many headache patients in a series of children met the diagnostic criteria of the IHS for migraine without aura or MD and to determine the changes required to convert the greatest number of MD into migraine without aura, without affecting classification of the remaining headache types. A prospective study was undertaken of 131 patients under 15 years old referred to our centre for headache. Patients were classified according to the IHS criteria and according to a modification of these criteria consisting of: (1) reduction of minimum time required for classification into migraine without aura from 2 h to 1 h; (2) acceptance of bifrontal location in addition to hemicranial; (3) acceptance of either phonophobia or photophobia as valid criteria instead of requiring presence of both. Using the IHS criteria, 51 (39%) children were diagnosed as having migraine without aura and 26 (20%) as having MD. According to our revised IHS criteria, 68 (52%) were diagnosed as migraine without aura and nine (7%) as MD. When the three modified criteria were applied, three tension headaches and one unclassifiable headache changed category. When only reduced duration and bifrontal location were applied, none of the headaches other than MD changed category. Application of two modifications to the IHS criteria--reduction in duration of headache to 1 h and acceptance of bifrontal location--increased sensitivity without reducing specificity in classifying migraine without aura in children.     

Current Aura Without Headache

Purpose of Review

This review evaluates and explains our current understanding of a rare subtype of migraine, typical aura without headache, also known as migraine aura without headache or acephalgic migraine.

Recent Findings

Typical aura without headache is a known entity within the spectrum of migraine. Its pathophysiology is suggested to be similar to classic migraines, with cortical spreading depression leading to aura formation but without an associated headache. No clinical trials have been performed to evaluate treatment options, but case reports suggest that most patients will respond to the traditional treatments for migraine with aura. Bilateral greater occipital nerve blocks may be helpful in aborting migraine with prolonged aura. Transcranial magnetic stimulation has shown efficacy in aborting attacks of migraine with aura but has not been specifically tested in isolated aura.

Summary

Typical aura without headache occurs exclusively in 4% patients with migraine, and may take place at some point in 38% of patients with migraine with aura. Typical aura without headache commonly presents with visual aura without headache, brainstem aura without headache, and can also develop later in life, known as late-onset migraine accompaniment.

     

Acephalgic Migraine

SYNOPSIS
Acephalgic migraine is a term used interchangeably with the term migraine equivalents. These terms by definition refer to any migrainous phenomena that may occur in the absence of a migraine headache.¹ Perhaps 20% of migraineurs may experience acephalgic attacks of migraine at one time or another. The idea that various symptoms can occur in the absence of any headache has been noted for hundreds of years, but very little has been written about this condition recently. Some people do not believe the symptoms that are often classified as migraine equivalents are in actuality part of the migraine syndrome. Because there is as yet no specific test for migraine, there is no proof that these various symptoms are due to the same neurovascular dysfunction we know as migraine. The diagnosis of migraine is based only on the patient's history and the exclusion of other diagnoses. It is not unusual for a headache patient to see several headache "specialists" and be given different diagnoses.
Some prefer the term "migraine accompaniments" for neurological or visual symptoms occurring with or without a headache.² The aura of the classic migraine attack may linger into the painful phase and thus "accompany" rather than just precede the headache. At times, symptoms typical of the aura may occur and may not be followed by a headache (acephalgic migraine). The term "complicated migraine"should probably be reserved for those neural and/or visual symptoms that outlast the headache by at least 24 hours and should not be used when referring to symptoms of shorter duration which may accompany the headache or which occur in the absence of migraine headache. Although non-visual migraine equivalents are not nearly as common as visual symptoms, it is important to recognize the fact that migraine may account for almost any recurrent, transient, episodic organ dysfunction.