Spontaneous Bilateral Internal Carotid Artery Dissection and Migraine: A Potential Diagnostic Delay

A 36-year-old man with a history of migraine without aura, presented with recurrent bouts of severe headache, perception of flashing lights in both visual fields, and transient bilateral neurological deficits. In view of his history, migraine with aura was considered. Ancillary investigations showed bilateral extracranial internal carotid artery dissection. This case illustrates that when attacks of severe headache with scotomata and transient bilateral neurological deficits occur in a patient with a history of migraine, the diagnosis of carotid artery dissection should be considered, especially when the pattern of headache is different or when some clinical characteristics have not been experienced previously.     

Visual contrast processing in migraine

Some migraine sufferers report certain visual patterns can reliably trigger a migraine attack, such as high contrast striped patterns or flickering lights. Differences between people with and without migraine on tasks that involve these patterns have been attributed to abnormal cortical processing in migraine, although the locus and extent of the abnormality remains unclear, as is any relationship between impairment on various visual tasks. In this study 58 migraine sufferers and 61 control subjects participated in three visual tasks involving striped patterns. One assessed pattern sensitivity with high contrast patterns, the second detection thresholds for low contrast patterns and the third supra-threshold contrast scaling. With each measure, the performance of migraine sufferers as a group differed to the performance of non-migraine control subjects. There were no significant differences between the migraine subgroups when classified according to the presence or absence of aura. Cross-correlating the results from the three tasks, however, revealed consistent associations: impaired or extreme responses on one task were associated with impaired or extreme responses on the others. There were no overall effects due to migraine duration, the frequency of migraine attacks or the time since the last attack. These results are discussed in the context of visually induced migraine, proposed causes of abnormal cortical function in migraine and the prospects for developing clinically useful tests of visual function.     

The influence of pattern interference on performance in migraine and visual discomfort groups

Performance in migraine with and without visual aura, non-specific headache and headache-free control groups was measured using a visual search task. Data from groups with high and low visual discomfort were also gathered. No pattern, 2 c/deg, 15 c/deg and a grey field were used in different background conditions. Presentation of patterned backgrounds slowed performance for all groups with the 2 c/deg pattern producing greatest interference. Performance of headache groups did not differ from that of the control group in any condition. The high visual discomfort group responded significantly more slowly than other groups with the 2 c/deg background. It was concluded that the presence of visual discomfort, reported on an everyday basis was a better indicator of heightened sensory sensitivity than the occurrence of migraine with or without aura.     

Visual field loss after attacks of migraine with aura

Visual fields were mapped with kinetic are perimetry in 23 migraine with aura subjects and, for comparison, in 20 migraine without aura subjects and in 21 non-headache controls. Central vision on the Amsler eye chart and visual perception threshold on a computer task were also investigated. Measures were obtained at least seven days after an episode of migraine. In addition, 10 of the migraine with aura subjects and 10 migraine without aura subjects were studied the day after an attack. The day after migraine with aura, visual sensitivity in the periphery of the visual fields was depressed, central vision was blurred, and visual perception threshold was elevated. These visual disturbances had resolved 7 to 10 days later. With the exception of a minor increase in visual perception threshold, vision was normal after attacks of migraine without aura. Residual effects of the migraine aura could mediate the subclinical visual disturbances which persist for at least one day after attacks of migraine with aura.     

Cognitive and behavioural effects of migraine in childhood and adolescence

Since cognitive and behavioural characteristics of paediatric migraine sufferers have yet to be adequately defined, in this study we assessed the effect of migraine on the interictal functioning of children and adolescents by comparing the performance of two patient groups, 17 migraine sufferers with aura (MA) and 31 without aura (MoA) and by correlating the duration of the disorder, the frequency of attacks and interictal period with neuropsychological and behavioural findings. Both patient groups had cognitive performance within normal range except for a significant delay in the reaction time (RT) task. Both MA and MoA revealed a behavioural phenotype characterized by internalizing problems on Child Behaviour Check List (CBCL) scales. Slower RT to simple visual stimuli may be an early sign of a subclinical neuropsychological dysfunction, significantly correlated with the frequency of headache attacks and interictal period. The lack of a control group and other methodological limitations, such as patient selection bias and unadjusted P-value for multiple testing, make it difficult to give this finding a clearcut meaning. Further studies are needed on larger samples compared with a control group.     

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).     

Perceived scintillation rate of migraine aura

OBJECTIVE: To measure the perceived rate of flicker (temporal frequency) observed during visual auras. BACKGROUND: The flickering or scintillating quality of aura elements is a commonly described characteristic of visual migraine auras. Hypotheses about the neural mechanisms involved in aura have rarely taken this feature into account, perhaps because of a lack of quantitative data on this aspect of the aura. While a rate of 10 Hertz had been suggested in the literature, estimates have been speculative due to the difficulty of judging temporal frequencies subjectively. METHODS: Eleven participants were given portable devices that contained an adjustable light-emitting diode with which to match the flickering of their auras. Observers were asked to make flicker matches at two time points so that rate change during aura progression could be analyzed. RESULTS: Data were obtained for 36 aura episodes. The mean rate of flicker across individuals was 17.8 Hertz. Rates varied widely between individuals, but were more consistent across multiple episodes in the same observer. Rate of flicker did not appear to relate to aura side or type, or to individual characteristics such as migraine history. When episodes were analyzed for change in flicker rate over time, patterns of increase (n = 7), decrease (n = 4), and no change (n = 22) were all observed. CONCLUSIONS: When measured with an objective task, aura scintillation rates were found to be somewhat higher than previous anecdotal observations had suggested. These data are discussed in the context of two competing hypotheses concerning the neural mechanism underlying the flicker percept during migraine aura.     

The similarities and differences of migraine with aura and migraine without aura: a preliminary study

A preliminary study was undertaken to provide clinical evidence to support the hypothesis that: "Migraine with aura, migraine without aura and aura alone are the same condition, which differ in degree rather than pathophysiology." At the City of London Migraine Clinic, 50 patients consecutively attending the clinic with a past or present history of migraine with aura were questioned. Of the 50 patients questioned 36 (70%) had a combination of migraine with aura, migraine without aura and/or aura alone; i.e. 70% had had more than one type of migraine attack. The duration, severity and frequency of attacks did not differ between migraine with and migraine without aura. Conclusion--the results support the hypothesis that migraine with and migraine without aura, and aura alone are not separate conditions, because: (1) most patients suffer from more than one type of migraine attack; (2) there are no significant differences in the characteristics of the migraine attacks in the different groups; (3) there are no significant differences in the characteristics of the subjects.     

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%.     

Transformation into daily migraine with aura following transcutaneous atrial septal defect closure

A link between migraine with aura and cardiac right-to-left shunting has been previously reported. Abortion or decreased frequency of migraine with aura attacks after atrial septal defect closure has been reported in the literature. We report the first case of transformation of migraine with aura into a daily pattern after atrial septal defect closure. A 48-year-old male who had been suffering from rather infrequent attacks of migraine with sensory and visual aura underwent transcutaneous closure of an atrial septal defect. His migraine attacks changed into a daily pattern the day following the procedure and remained so for 6 months. This change in pattern may be related to a changed intra-atrial pressure after the closure or some other unknown factor.     

Cessation of hemiplegic migraine auras with greater occipital nerve blockade

Prolonged migraine auras can be disabling and potentially can cause permanent neurologic deficits. Several medicinal agents have shown some efficacy in aborting prolonged auras, but results are inconsistent. Greater occipital nerve blockade can alleviate the pain of migraine and in 1 case report the migraine aura. Hemiplegic migraine attacks are marked by motor weakness that can last for minutes to days. Two case patients with a history of hemiplegic migraine with prolonged auras are presented, who both had complete alleviation of their aura symptoms with GON blockade. A hypothesis on how GON blockade may inhibit cortical spreading depression is also presented.     

Interictal executive dysfunction in migraineurs without aura: relationship with duration and intensity of attacks

Subjects with migraine are at increased risk of subcortical white matter lesions (WML). Reports of cognitive testing in adults with migraine have yielded inconsistent results. We performed a cross-sectional study to assess whether migraine without aura (MwA) is associated with impairment in executive functioning, a typical cognitive correlate of subcortical WML. Forty-five subjects with MwA and 90 controls, matched for age and education, underwent a cognitive battery of tests evaluating executive functions. The following migraine characteristics were collected: age at onset and length of migraine history, and frequency, duration and intensity of attacks. Subjects with MwA performed significantly lower than controls in tests evaluating complex, multifactorial executive functions. After multiple adjustments, the duration and intensity of migraine attacks significantly predicted cognitive disturbances. In the interictal phase of MwA there is evidence of mild executive dysfunction. The cumulative effects of repeated migraine attacks on prefronto-cerebellar loop probably account for our results.     

Daily migraine with visual aura associated with an occipital arteriovenous malformation

A 51-year-old woman with daily attacks of migraine with visual aura is described. The aura always occurred on the right and the headache always on the left side of the head, suggesting a structural lesion in the left occipital lobe. The lesion appeared to be an arteriovenous malformation of which almost full obliteration resulted in a decrease in frequency of the aura and in intensity of the headache. Subsequent treatment of borderline hypothyroidism with levothyroxine brought about a dramatic improvement in frequency of both the aura and the headache. The case is discussed in the light of our present understanding of the pathogenesis of the migraine attack.     

The aura: a tertiary care study of 952 migraine patients

The aim of this study was to document the frequency and types of aura symptoms, to define the relationship between aura symptoms and to define the aura frequency in different migraine types. In 952 migraine patients, aura frequency, duration, time to headache, characteristics and percentage of headaches with aura were analysed. Thirty-eight percent of IHS 1.1-1.5 patients reported aura, 38.1% of females and 33.0% of males. Average percentage of aura occurrence with headache was 19.7% of headaches, average aura duration 27.3 min and aura was followed by headache in 10.4 min on average. Visual disturbances occurred in 92.1% and aura without visual aura was rare. Aura frequency was headache-type dependent. The highest frequency of aura was seen in the more 'full-blown' migraine attack. Visual aura is the overwhelming aura symptom. Even in patients with aura the percentage of aura with migraine attacks is limited.     

EEG features in juvenile migraine: topographic analysis of spontaneous and visual evoked brain electrical activity: A comparison with adult migraine

Topographic analysis of spontaneous and steady-state visual evoked brain electrical activity was carried out between attacks in 82 migraine patients (40 youths and 42 adults). In adult migraine with aura a significant increase of delta rhythm percentage power was observed compared with migraine without aura and age-matched controls. Children suffering from migraine both with aura and without aura had an increased theta rhythm compared to normal controls. The presence of alpha interhemispheric asymmetry discriminated between migraine with aura and without aura, just as in adults. An increased amplitude of the SVEP F1 component with a tendency to the spread of visual reactivity was observed in juvenile migraine with and without aura; this pattern was not dissimilar from the one previously observed in adult migraine with and without aura. Abnormal photic driving in migraine is independent of age and type of migraine.     

Light-induced discomfort and pain in migraine

Quantitative thresholds for discomfort and pain with monocular and binocular light stimuli were measured in 67 controls and 67 migraine patients 37 migraine with aura and 30 migraine without aura). Patients were more photophobic during attack than outside attack ( p <0.03), and they were more sensitive to light than controls even between attacks ( p 0001). We found no differences in light sensitivity between migraine with aura and migraine without aura ( p 0.93). Unilateral pain affected light sensitivity on both sides. When asked with a questionnaire, 74% of patients answered that they were sensitive to light outside attack and 100% were sensitive during attack. Pain thresholds were generally lower among sensitive than non-sensitive patients ( p =0.004), indicating some agreement between subjective opinion and objective measurements of photophobia. Photophobia seems to be an intrinsic property of migraineurs. It is increased by migraine pain, but seems to be unrelated to migraine characteristics such as nausea, severity of attacks, pain character and pain laterality.     

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.     

Relationship between migraine and patent foramen ovale: a study of 121 patients with migraine

BACKGROUND: Migraine is a common neurological disorder, the origins of which remain unknown. Patent foramen ovale (PFO) is considered to have a role in migraine. The relationship between migraine and patent foramen ovale may be stronger in patients suffering from migraine with aura compared to patients with common migraine. OBJECTIVES: The aim of the study was to evaluate the frequency of PFO in patients with migraine with aura (MA+) and compare it with the prevalence of PFO in migraine patients without aura (MA-), and in a healthy age-matched control group. We investigated PFO association with migraine, considering such factors as: A type of migraine aura, frequency of attacks, familial occurrence, sex and age of patients. Patients.-121 patients: 61 patients suffering from migraine with aura, 60 without aura and 65 normal controls. The group of patients with migraine with aura was divided into subgroups regarding to the type of aura. METHODS: In order to detect PFO the contrast transcranial Doppler was performed during Valsalva maneuver. RESULTS: The presence of PFO was found in 33/61 (54%) patients with MA(+) compared to 15/60 (25%) without aura and 16/65 (25%) control subjects. The difference between MA(+) patients and MA(-) patients and the difference between MA(+) patients and control group was statistically significant (P < .05). There was no association between type of migraine aura and PFO, as well as we found no association between PFO and frequency of attacks, familial occurrence, sex and age of patients and PFO. CONCLUSIONS: Our findings suggest possible association of migraine with aura and PFO. It seems that PFO does not influence the type of aura and frequency of attacks of migraine as well as it is not associated with familial occurrence of migraine.     

Cranial magnetic resonance imaging findings in patients with migraine

OBJECTIVE: To investigate the frequency of cranial magnetic resonance imaging abnormalities in patients with migraine and their relationship to type, duration, and frequency of migraine attacks. METHODS: Forty-five patients (43 women, 2 men) with migraine whose ages ranged between 19 and 53 years (mean, 40.91 [SD, 7.69]) were evaluated. Of the 45 patients, 20 had migraine with aura and 25 had migraine without aura, according to the diagnostic criteria of the International Headache Society. RESULTS: In 13 (28.8%) of 45 patients, white matter foci were present on magnetic resonance imaging. Eight of these patients (61.5%) had migraine with aura, and 5 patients (38.4%) had migraine without aura. The presence of white matter foci was significantly higher in the patients with aura (8 [40%] of 20) than in those without aura (5 [20%] of 25). It was found that as the frequency of attacks per month increased, the number of patients with white matter foci also increased. Although the mean duration of migraine was longer in patients with white matter foci (149.5 months [SD, 87.9]) than in those without white matter foci (134.1 months [SD, 88.3]), there was no significant difference (P >.05). CONCLUSION: Although there are no specific magnetic resonance imaging findings peculiar to migraine, detection of white matter foci should be taken into consideration in patients with migraine (especially migraine with aura). Frequency of attacks is an important indicator of existence of white matter foci.     

Calcitonin gene-related peptide does not cause migraine attacks in patients with familial hemiplegic migraine

(Headache 2011;51:544‐553) Background.— Calcitonin gene‐related peptide (CGRP) is a key molecule in migraine pathogenesis. Intravenous CGRP triggers migraine‐like attacks in patients with migraine with aura and without aura. In contrast, patients with familial hemiplegic migraine (FHM) with known mutations did not report more migraine‐like attacks compared to controls. Whether CGRP triggers migraine‐like attacks in FHM patients without known mutations is unknown. Objective.— In the present study we therefore examined the migraine‐inducing effect of CGRP in FHM patients without known mutations and healthy controls. Methods and design.— Eleven patients suffering from FHM without known mutations and 11 controls received an intravenous infusion of 1.5 µg/minute CGRP over 20 minutes. The study design was a balanced and controlled provocation study. Headache and other migraine symptoms were scored for 1 hour and self‐recorded hourly thereafter until 13‐hour postinfusion. Results.— We found no difference in the incidence of migraine‐like attacks between the 2 groups, with 9% (1 of 11) of patients and 0% (0 of 10) of controls reporting migraine‐like headache (P = 1.00). CGRP infusion did not induce aura symptoms in any of the participants. There was no difference in the incidence of CGRP‐induced delayed headaches between the groups (P = .18). Conclusion.— In contrast to patients suffering from migraine with aura and without aura, CGRP infusion did not induce more migraine‐like attacks in FHM patients without known mutations compared to controls. It seems that the majority of FHM patients with and without known mutation display no sensitivity to CGRP signaling compared to common types of migraine.