Migraine aura without headache

Shih-Pin Chen MD PhD (Dr. Chen of the National Yang-Ming University School of Medicine has no relevant financial relationships to disclose.)
Shuu-Jiun Wang MD, editor. (Dr. Wang of the National Yang-Ming University School of Medicine and the Neurological Institute, Taipei Veterans General Hospital received consulting fees from Eli Lilly.)
Originally released December 30, 1993; last updated March 20, 2017; expires March 20, 2020

This article includes discussion of migraine aura without headache and acephalgic migraine. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Migraine is a common neurologic disorder that is prevalent in the younger population. With age, migraine prevalence decreases, but some people continue to experience migraine auras without the subsequent or associated headache pain. In this article, the author reviews the clinical manifestations, prevalence, pathophysiology, therapeutic options, and prognosis for this selective group of patients. Breakthroughs in understanding the pathogenesis and clinical manifestations are highlighted.

Key points

 

• Typical aura is consisted of visual, sensory, or speech symptoms with a mix of positive and negative features and complete reversibility.

 

• Migraine aura could initiate from multiple distinct sites, propagate nonconcentrically with a variable extent in the occipital cortex, and can sometimes be clinically “silent”.

 

• Differential diagnoses, including transient ischemic attack, should be considered when aura is late-onset with predominant negative features or is prolonged or of very short duration.

 

• Cortical spreading depression, glutamatergic neurotransmission, channelopathies, neuronal-glial gap-junction communications, and microembolization might be important players in the pathogenesis of migraine aura.

 

Migraine with aura is associated with higher risks of subclinical brain lesions, ischemic or hemorrhagic strokes, and all cause mortalities; whether this remains true for “migraine aura without headache” requires further studies.

Historical note and terminology

Migrainous aura has been used to explain unusual visions, experiences, and perceptions that have been experienced by well-known personages. Lewis Carroll's pictorial descriptions in Alice in Wonderland and Alice Through the Looking Glass have been ascribed to his migrainous auras. His depiction of Alice may be a manifestation of the micropsia, macropsia, or metamorphopsia seen in migrainous auras of childhood.

There have also been suggestions that the painter Pablo Picasso may have had migrainous auras. His works feature illusory splitting in the vertical plane of his subjects' faces, and this has been compared to similar paintings by migraine patients depicting what they see during their aura phase (Podoll 2000). The absence of descriptions of the painter suffering from headaches may infer the presence of migraine aura without headache.

Fisher described a series of 120 patients: 25 had only visual symptoms; 18 had visual symptoms and paresthesias; 7 had visual symptoms and speech disturbances; 14 had visual and brainstem symptoms; 7 had visual symptoms, paresthesias, and speech disturbances; 25 had visual symptoms, paresthesias, speech disturbances, and paresis; 9 had recurrence of old stroke deficit; and 8 had miscellaneous symptoms (Fisher 1980). In 1986, a study of 85 cases demonstrated that 21 patients had visual symptoms; 6 had visual symptoms and paresthesias; 2 had visual symptoms and speech disturbances; 3 had visual symptoms, paresthesias and speech disturbances; 20 had visual symptoms, paresthesias, speech disturbances, and weakness; 3 had visual and brainstem symptoms; and 32 were without visual symptoms. Their ages ranged from 40 to 73 years. In only 40% of cases did headache occur in association with the episodes. These episodes have been coined ‘‘late-life migraine accompaniments,” “migraine equivalents,” “acephalic migraine,” or “migraine aura without headache.”

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