Migraine and Aura

Visual Aura - What It Is and Isn't
What Forms Can Aura Take?
Migraine with Aura and Strokes? Vitamin B May Help?
Migraine with Aura
Migraine Without Aura


Visual Aura: What it Is and Isn't

Many people with migraine have changes in their vision around the time of their headaches. Blurry vision and sensitivity to bright lights are two commonly mentioned problems. They can begin before the headache itself and may last throughout the migraine attack.
Some people, though, have more dramatic changes in vision that doctors refer to as visual aura. In visual aura, the vision changes might include such things as losing part or all of one’s vision for a short period of time, or seeing zig-zag or squiggly lines. Typically these visual symptoms come on gradually, develop over a period of about half an hour, and fade away as the migraine headache begins. The entire episode usually does not last longer than an hour. Some people with migraine have other types of aura, in which they experience problems such as numbness, tingling or weakness. An interesting fact, though, is that almost all of them also experience visual aura.
Only about a third of people with migraine have migraine with visual aura, and aura may occur with only some and not all of their headaches. It is also possible to have an aura that is not followed by a headache; this becomes more common as people get older.
It is not always easy to tell the difference between some of the typical vision changes that accompany migraine and those that are considered to be true visual aura.  Doctors commonly try to divide people with migraine into those who have migraine without aura and those who have migraine with aura. Why does this matter? Treatment of the two kinds of migraine is usually the same but other advice may be different. Migraine with aura slightly increases the risk of having a stroke, for example, and women who have migraine with aura need to think carefully about the risks of treatments such as birth control pills that contain estrogen.
Elizabeth Loder, MD, MPH, FAHS
Chief, Division of Headache and Pain, BWH/Faulkner Neurology
John R. Graham Headache Center
Boston, MA
 

What Forms Can Migraine Aura Take?

What do you think of when you think about the aura phase of Migraine attack? Stop and think about that for a moment before you continue reading.

Most people think of the possible visual symptoms, including:

  • scotoma, an area of decreased or lost vision;
  • phosphenes, brief flashes of light that streak across the visual field;
  • blurry vision;
  • wavy lines, which some people describe as being similar to how things appear on a hot day when viewed through the heat rising off pavement and other surfaces; and
  • other visual symptoms.

There are some people who have been misinformed and think that aura must be visual. There are many other possible aura symptoms, including:

  • aphasia, the loss or impairment of the power to use or comprehend language, including both words and numbers;
  • allodynia, hypersensitivity to feel and touch (this symptom is what causes some people to say that even their hair hurts during a Migraine);
  • dizziness;
  • confusion;
  • metamorphosia, a distortion of body image and perspective that can occur with a rare aura called Alice in Wonderland Syndrome; and
  • many other symptoms, including hiccups.

Recognizing the Migraine aura can be important and helpful. Studies have shown that Migraine-specific medications such as the triptans (Imitrex, Maxalt, Zomig, etc.) work better when taken early in the Migraine attack.

____________
Resources:

Evans, Randolph W. & Rolak, Loren A. (2004) Expert Opinion. Headache, The Journal of Head and Face Pain 44 (6), 624-625. doi: 10.1111/j.1526-4610.2004.446013.x

Evans, Randolph W.; Mathew, Ninan T. "Handbook of Headache," Second Edition. Lippincott Williams & Wilkins. 2005.

Young, William B., M.D.; Silberstein, Stephen D., M.D. "Migraine and Other Headaches." American Academy of Neurology Press. 2004.

Robert, Teri. "Living Well with Migraine Disease and Headaches." HarperCollins. 2005.

Chaudry, P.; Friedman, D.I. "Hiccups as a Migraine Aura." Poster Presentation P279. International Headache Congress. June, 2013.


© Teri Robert, 2013. All Rights Reserved.
Last updated August 26, 2013.

Medical Review by John Claude Krusz, MD, PhD.


Migraine With Aura and Strokes? B Vitamins May HELP?

By Alexander Mauskop, MD, FAAN
 
People who suffer from migraines with aura are at a slightly increased risk of having strokes. The cause of this association is not known. However, recent research suggests that having migraine aura is also a risk factor for having a genetic abnormality which raises homocysteine levels. Homocysteine is an amino acid, which occurs naturally in the body, but having too much homocysteine is known to increase the risk of strokes and heart attacks. It is possible that the increased risk of strokes in migraine with aura is due to elevated homocysteine level. Having migraine with aura does not increase the risk of heart attacks, so high homocysteine is probably only a partial reason. Fortunately, to reduce homocysteine level all one has to do is take vitamins B12, B6, and folic acid. Australian researchers who discovered this link between migraine with aura and high homocysteine level also conducted a treatment study. They gave half of the patients vitamin supplements and the other half, placebo. Patients who took vitamins had lower homocysteine levels (and possibly the risk of strokes) and also had fewer and milder migraine attacks, compared to patients who took placebo. The dose used in the study was 2 mg of folic acid, 25 mg of vitamin B6, and 400 mcg of vitamin B12. If you suffer from migraine with aura you may want to ask your doctor to check your homocysteine level. If your level is high, take these vitamins – they may help with no risk of side effects.
 
Alexander Mauskop, MD, FAAN
New York Headache Center
30 East 76 Street
New York, NY 10021
212-794-3550
www.NYHeadache.com
 

Migraine with Aura

Migraine is a common disabling primary headache disorder. Epidemiological studies have documented its high prevalence and high socioeconomic and personal impacts. It is now ranked by the World Health Organization as number 19 among all diseases world-wide causing disability.
 
Migraine is a genetic neurological disease. Because there are several different types of Migraine, and some forms involve different genetic markers, some researchers theorize that it may actually be more than one disease. For now, however, Migraine is divided into two major subtypes, Migraine without aura (MWOA) and Migraine with aura (MWA). There is a single classification under Migraine without aura. MWOA is the most common form of Migraine. MWA is the second most common, occurring in 25-30% of Migraineurs. Few people have the aura phase with every Migraine attack. Thus, it’s quite common to be diagnosed with both MWA and MWOA.
 
For consistency in diagnosing and classifying head pain disorders, the International Headache Society’s International Classification of Headache Disorders, Second Edition (ICHD-II), is generally accepted as the "gold standard." Hemiplegic and basilar-type Migraine are subtypes of Migraine with aura. For the purposes of this article, we’ll be discussing 1.2.1, "typical aura with migraine headache." The ICHD-II classification criteria:
 
1.2 Migraine with aura
Previously used terms:
Classic or classical migraine, ophthalmic, hemiparaesthetic, hemiplegic or aphasic migraine, migraine accompagnée, complicated migraine
 
1.2.1 Typical aura with migraine headache
 
Description:
Typical aura consisting of visual and/or sensory and/or speech symptoms. Gradual development, duration no longer than one hour, a mix of positive and negative features and complete reversibility characterise the aura which is associated with a headache fulfilling criteria for 1.1 Migraine without aura.
 
Diagnostic criteria:
 
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 symptoms1 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
 
* If the aura includes motor weakness, code as 1.2.4 Familial hemiplegic migraine or 1.2.5 Sporadic hemiplegic migraine.
 
Some differences in children:
  1. In children, attacks may last 1–72 hours.
  2. The headache of a migraine attack is commonly bilateral (on both sides) in young children; an adult pattern of unilateral pain usually emerges in late adolescence or early adulthood.
  3. In young children, photophobia and phonophobia may be inferred from observing their behavior.
  4. The headache of a Migraine attack is usually frontotemporal (front and sides, toward the front, of head). Occipital (lower back of the head) headache in children, whether unilateral or bilateral, is rare and calls for caution in diagnosing as many cases are attributable to structural lesions.
In MWA, a Migraine attack can consist of up to three phases:
1. Prodrome
2. Aura
3. Headache Phase
4. Postdrome
The Prodrome
The prodrome (sometimes called preheadache or premonitory phase) may be experienced hours or even days before a Migraine attack. The prodrome may be considered to be the Migraineur's "yellow light," a warning that a Migraine is imminent. For the 30 to 40% of Migraineurs who experience prodrome, it can actually be very helpful because, in some cases, it gives opportunity to abort the attack. For Migraineurs who experience prodrome, it makes a solid case for keeping a Migraine diary and being aware of one's body.
Potential symptoms of the prodrome are:
• food cravings
• constipation or diarrhea
• mood changes — depression, irritability, etc.
• muscle stiffness, especially in the neck
• fatigue
• increased frequency of urination
• yawning
The Aura
The aura is perhaps the most talked about of the possible phases. The symptoms and effects of the aura vary widely. Some can be quite terrifying, especially when experienced for the first time. Some of the visual distortions can be exotic and bizarre. It's interesting to note that Migraine aura symptoms are thought to have influenced some famous pieces of art and literary works. One of the better know is Lewis Carroll's "Alice in Wonderland."
While most people probably think of aura as being strictly visual, auras can have a wide range of symptoms, including:
• visual: flashing lights, wavy lines, spots, partial loss of sight, blurry vision
• olfactory hallucinations — smelling odors that aren't there
• paresthesia - tingling or numbness of the face or extremities aphasia - difficult finding words and/or speaking
• partial paralysis (only in hemiplegic Migraine)
• decrease in hearing
• reduced sensation
• allodynia - hypersensitivity to feel and touch
• brief flashes of light that streak across the visual field (phosphenes)
Approximately 25% of Migraineurs experience aura. As with the prodrome, Migraine aura, when the Migraineur is aware of it, can serve as a warning, and sometimes allows the use of medications to abort the attack before the headache phase begins. As noted earlier, not all Migraine attacks include all phases. Although not the majority of attacks, there are some Migraine attacks in which Migraineurs experience aura but no headache. There are several terms used for this experience, including "silent Migraine," "acephalgic Migraine."
The Headache
The headache phase is generally the most debilitating part of a Migraine attack. It's effects are not limited to the head only, but affect the entire body. The pain of the headache can range from mild to severe. It can be so intense that it is difficult to comprehend by those who have not experienced it. Characteristics of the headache phase may include:
• headache pain that is often unilateral — on one side. This pain can shift to the other side or become bilateral.
• Although Migraine pain can occur at any time of day, statistics have shown the most common time to be 6 a.m. It is not uncommon for Migraineurs to be awakened by the pain.
• Because trigeminal nerve becomes inflamed during a Migraine, Migraine pain can also occur in the areas of the eyes, sinuses, and jaw.
• This phase usually lasts from one to 72 hours. In less common cases where it lasts longer than 72 hours, it is termed status Migrainous, and medical attention should be sought.
• The pain is worsened by any physical activity.
• phonophobia — increased sensitivity to sound
• photophobia — increased sensitivity to light
• osmophobia — increased sensitivity to odors
• neck pain
• nausea and vomiting
• diarrhea or constipation
• nasal congestion and/or runny nose
• depression, severe anxiety
• hot flashes and chills
• dizziness
• vertigo - sensation of spinning or whirling (not to be confused with dizziness or light-headedness)
• confusion
• dehydration or fluid retention, depending on the individual body's reactions
The Postdrome
Once the headache is over, the Migraine attack may or may not be over. The postdrome (sometimes called postheadache) follows immediately afterward. The majority of Migraineurs take hours to fully recover; some take days. Many people describe postdrome as feeling "like a zombie" or "hung-over." These feelings are often attributed to medications taken to treat the Migraine, but may well be caused by the Migraine itself. Postdromal symptoms have been shown to be accompanied and possibly caused by abnormal cerebral blood flow for up to 24 hours after the end of the headache stage. In cases where prodrome and/or aura are experienced without the headache phase, the postdrome may still occur. The symptoms of prodrome may include:
• lowered mood levels, especially depression
• or feelings of well-being and euphoria
• fatigue
• poor concentration and comprehension
• lowered intellect levels
A MWA attack can skip the headache phase. In that case, it’s described as "acephalgic" or "silent" Migraine with aura; the diagnosis is still Migraine with aura.
It’s important to note that you can have more than one type of Migraine. It’s also not unusual to experience both tension-type headaches and Migraines. If your doctor has diagnosed you with "Migraines," ask for a more definitive diagnosis. That will make it easier for you to find information and learn about Migraine disease as it applies to you.
____________
Resources:
1 The International Headache Society. "International Classification of Headache Disorders, 2nd Edition." Cephalalgia, Volume 24 Issue s1. May, 2004. doi:10.1111/j.1468-2982.2003.00823.x.
2 Young, William B., MD; Silberstein, Stephen D., MD. "Migraine and Other Headaches." AAN Press. St. Paul. 2004.
3 Calhoun, Anne H., MD; Ford, Sutapa, PhD; Millen, Cori, DO; Finkel, Alan G., MD; Truong, Young, PhD; Nie, Yonghong, MS. "The Prevalence of Neck Pain in Migraine." Headache. Published Online: Jan. 20, 2010.
Migraine With Aura - The Basics. Written by Teri Robert and published on MyMigraineConnection.com. Copyright 2004 - Present, Teri Robert. All rights reserved. http://www.healthcentral.com/migraine/types-of-headaches-44990-5.html. Last updated July 5, 2011. Medical review by John Claude Krusz, PhD, MD

Migraine Without Aura

Migraine is a common disabling primary headache disorder. Epidemiological studies have documented its high prevalence and high socioeconomic and personal impacts. It is now ranked by the World Health Organization as number 19 among all diseases world-wide causing disability.
 
Migraine is a genetic neurological disease. Because there are several different types of Migraine, and some forms involve different genetic markers, some researchers theorize that it may actually be more than one disease. For now, however, Migraine is divided into two major subtypes, Migraine without aura (MWOA) and Migraine with aura (MWA). There is a single classification under Migraine without aura. MWOA is the most common form of Migraine.
 
For consistency in diagnosing and classifying head pain disorders, the International Headache Society’s International Classification of Headache Disorders, Second Edition (ICHD-II), is generally accepted as the "gold standard." The ICHD-II classification criteria for Migraine without aura is:
 
1.1 Migraine without aura
 
Previously used terms: Common migraine, hemicrania simplex
 
Description:
Recurrent headache disorder manifesting in attacks lasting 4–72 hours. Typical characteristics of the headache are unilateral (one-sided) location, pulsating quality (throbbing or varying with the heartbeat), moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia (increased sensitivity to light) and phonophobia (increased sensitivity to sound).
 
Diagnostic criteria:
A.      At least 5 attacks fulfilling criteria B–D
B.      Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated)
C.      Headache has at least two of the following characteristics:
1.       unilateral location
2.       pulsating quality
3.       moderate or severe pain intensity
4.       aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
D.      During headache at least one of the following:
1.       nausea and/or vomiting
2.       photophobia and phonophobia
3.       Not attributed to another disorder
Some differences in children:
  1. In children, attacks may last 1–72 hours.
  2. The headache of a Migraine attack is commonly bilateral (on both sides) in young children; an adult pattern of unilateral pain usually emerges in late adolescence or early adulthood.
  3. In young children, photophobia and phonophobia may be inferred from observing their behavior.
  4. Occipital (lower back of the head) headache in children, whether unilateral or bilateral, is rare and calls for caution in diagnosing as many cases are attributable to structural lesions.
In MWOA, a Migraine attack can consist of up to three phases:
  1. Prodrome
  2. Headache Phase
  3. Postdrome
The Prodrome
The prodrome (sometimes called preheadache or premonitory phase) may be experienced hours or even days before a Migraine attack. The prodrome may be considered to be the Migraineur's "yellow light," a warning that a Migraine is imminent. For the 30 to 40% of Migraineurs who experience prodrome, it can actually be very helpful because, in some cases, it gives opportunity to abort the attack. For Migraineurs who experience prodrome, it makes a solid case for keeping a Migraine diary and being aware of one's body.
 
Potential symptoms of the prodrome are:
  • food cravings
  • constipation or diarrhea
  • mood changes — depression, irritability, etc.
  • muscle stiffness, especially in the neck
  • fatigue
  • increased frequency of urination
  • yawning
  • neck pain
The Headache
The headache phase is generally the most debilitating part of a Migraine attack. Its effects are not limited to the head only, but affect the entire body. The pain of the headache can range from mild to severe. It can be so intense that it is difficult to comprehend by those who have not experienced it. Characteristics of the headache phase may include:
  • headache pain that is often unilateral — on one side. This pain can shift to the other side or become bilateral.
  • Although Migraine pain can occur at any time of day, statistics have shown the most common time to be 6 a.m. It is not uncommon for Migraineurs to be awakened by the pain.
  • Because trigeminal nerve becomes inflamed during a Migraine, Migraine pain can also occur in the areas of the eyes, sinuses, and jaw.
  • This phase usually lasts from one to 72 hours. In less common cases where it lasts longer than 72 hours, it is termed status Migrainous, and medical attention should be sought.
  • The pain is worsened by any physical activity.
  • phonophobia — increased sensitivity to sound
  • photophobia — increased sensitivity to light
  • osmophobia — increased sensitivity to odors
  • neck pain
  • nausea and vomiting
  • diarrhea or constipation
  • nasal congestion and/or runny nose
  • depression, severe anxiety
  • hot flashes and chills
  • dizziness
  • vertigo - sensation of spinning or whirling (not to be confused with dizziness or light-headedness)
  • confusion
  • dehydration or fluid retention, depending on the individual body's reactions
The Postdrome
Once the headache is over, the Migraine attack may or may not be over. The postdrome (sometimes called postheadache) follows immediately afterward. The majority of Migraineurs take hours to fully recover; some take days. Many people describe postdrome as feeling "like a zombie" or "hung-over." These feelings are often attributed to medications taken to treat the Migraine, but may well be caused by the Migraine itself. Postdromal symptoms have been shown to be accompanied and possibly caused by abnormal cerebral blood flow for up to 24 hours after the end of the headache stage. In cases where prodrome and/or aura are experienced without the headache phase, the postdrome may still occur. The symptoms of prodrome may include:
  • lowered mood levels, especially depression
  • or feelings of well-being and euphoria
  • fatigue
  • poor concentration and comprehension
  • lowered intellect levels
A MWOA attack can skip the headache phase. In that case, it’s described as "acephalgic" or "silent" Migraine without aura; the diagnosis is still Migraine without aura.
It’s important to note that you can have more than one type of Migraine. It’s also not unusual to experience both tension-type headaches and Migraines. If your doctor has diagnosed you with "Migraines," ask for a more definitive diagnosis. That will make it easier for you to find information and learn about Migraine disease as it applies to you.
____________
Resources:
1 The International Headache Society. "International Classification of Headache Disorders, 2nd Edition." Cephalalgia, Volume 24 Issue s1. May, 2004. doi:10.1111/j.1468-2982.2003.00823.x.
2 Young, William B., MD; Silberstein, Stephen D., MD. "Migraine and Other Headaches." AAN Press. St. Paul. 2004.
3 Calhoun, Anne H., MD; Ford, Sutapa, PhD; Millen, Cori, DO; Finkel, Alan G., MD; Truong, Young, PhD; Nie, Yonghong, MS. "The Prevalence of Neck Pain in Migraine." Headache. Published Online: Jan. 20, 2010.
 
Migraine Without Aura - The Basics. Written by Teri Robert and published on MyMigraineConnection.com. Copyright 2004 - Present, Teri Robert. All rights reserved. http://www.healthcentral.com/migraine/types-of-headaches-44979-5.html Last updated July 3, 2011. Medical review by John Claude Krusz, PhD, MD
 
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