Migraine is one of the most common forms of primary headache, and can occur with or without “aura”. From the point of view of the intensity, duration and location of pain, as well as factors that can facilitate the triggering or worsen the course of headache and associated symptoms, such as irritability, sweating, sensitivity to light or sounds (phonophobia), migraine with or without aura are completely identical. What differentiates the first from the second is a set of visual and / or sensory symptoms, sometimes accompanied by speech disorders, which gradually begin to manifest themselves from 5 to 60 minutes before the typical migraine throbbing pain arises, and then regresses spontaneously, as they appeared, while the latter takes over.
What is migraine aura
The aura is a typical manifestation of migraine that can sometimes occur even in those suffering from cluster headache, but which is never experienced in case of tension-type headache (form of headache mainly linked to fatigue and stress in which the pain tends to develop gradually and to be of the “burdensome” type, that is, that causes the feeling of weight).
According to the International Headache Society’s (IHS) International Classification of Headaches, migraine aura can be of a different type depending on the sensations experienced by those affected.
The so-called “typical aura” essentially includes:
| Alterations in vision | Appearance of sparkling scotomas (black or coloured spots), flashes of light, bright dots or other changes in the field of vision (e.g. water flowing in front of the eye, blurred vision, distortion of images, narrowing of the field of vision, etc.) |
| Alterations in sensitivity | Tingling, pinpricks or loss of sensation, sensations of cold or hot to the face, especially at the level of the mouth, fingers, of the tongue and the side of the skull which will then also be affected by the pain |
When, in addition to these manifestations, there are also neurological symptoms referable to an altered functionality of the nerves of the brainstem (the tract of nervous system that connects the brain to the spinal cord and that “hosts” all the roots of the nerves responsible for the sensitivity and motor control of the head and neck), we speak instead of “brainstem aura, in English).
In this second case, in addition to the symptoms already mentioned, dizziness (resulting in nausea), tinnitus (a sort of sound hallucination similar to a more or less persistent hiss), hearing reduction, doubling of images, difficulty concentrating and coordinating movements may occur.
In none of the forms of migraine aura should be present significant motor symptoms, such as muscle weakness or movement deficit (ie partial or total paralysis, but always completely reversible at the end of the attack), vice versa the diagnosis is of “hemiplegic migraine”. Absent (both in the forms with aura and in those without aura) is also lacrimation, which is instead among the typical symptoms of cluster headache.
Causes of migraine with aura
The exact causes of migraine aura, even more than those of migraine tout court, are not known. Given the characteristics of visual disturbances, it is hypothesized that at the origin of the phenomenon there may be an abnormal electrical activity, or an altered secretion of the neurotransmitters that trigger it, in the areas of the brain involved in the propagation of visual stimuli and in image processing (optic nerve and chiasm and visual cortex).
As regards, more generally, the factors that can increase the risk of suffering from migraine with aura or favoring the onset of an attack, experience indicates that they are similar to those typical of migraine without aura.
In particular, migraine is more frequent in women, affected up to four times more than men, especially after puberty (15-40 years) probably for hormonal reasons, and people who have a genetic predisposition for the disorder (familiarity).
Supporting the idea that female hormones (estrogen) may play a role in promoting migraine development and the triggering of attacks is the evidence that seizures tend to thin out or be less severe during pregnancy. In addition, it is widespread experience that the frequency of migraine attacks changes during the menstrual cycle, often concentrating in the 2 days preceding the onset of menstruation, and that it is greater in the female population taking hormonal contraceptives or other therapies containing female hormones.
Migraine attacks are generally also favored by exposure to very common stimuli, such as marked or prolonged psychophysical stress, exposure to light or intense noises, insomnia or excessive sleep.
Nutrition can also contribute to triggering crises both in general terms (unbalanced diet, long fasts, binges, etc.) and in relation to the intake of particular foods (aged cheeses, wine and spirits, glutamate, oriental foods, fried, chocolate, coffee, etc.).
Migraine is also a known side effect of some medications, including hormonal contraceptives, nitrates, opioids, erectile dysfunction drugs, as well as the same analgesic and anti-inflammatory drugs used to counteract it, if taken too often or improperly.
It must be said, however, that compared to forms of migraine without aura, the triggering factors of forms with anticipatory symptoms are much more variable and less easily characterized, therefore also more difficult to remove with a view to prevention.
Although rarely, migraine can also affect children: in these cases the characteristics of the headache they suffer from must be investigated with particular attention, in order to remove the possible causes and / or aggravating factors and limit as much as possible the use of drug therapies. When necessary to appease a significant malaise in children, anti-migraine drugs should always be prescribed by a specialist in neurology after a thorough evaluation.
Symptoms of migraine with aura
Migraine with aura is less common than migraine without aura: it is estimated that of all migraine patients only 15-18 percent experience warning symptoms of the attack. In 80 percent of cases, aura symptoms are exclusively visual and, on average, their duration is 20-30 minutes.
The headache that occurs within the hour following the onset of the aura can be so intense as to be disabling (similar to what happens in the case of cluster headache), preventing not only to carry out a work activity that requires concentration or intellectual commitment, but also the most common daily tasks and interaction with other people. In fact, the only relief is given by resting in a lying position in bed, in a quiet, dark or poorly lit room (so as not to solicit photophobia) and free of unpleasant odors that could worsen any nausea associated with migraine.
In more than 50 percent of cases, the pain of migraine with aura is concentrated on only one side of the head and is often pulsating, but is usually less intense than that of migraine without aura. In a minority of cases, after the aura, no painful crisis develops: in these cases we speak of “typical aura without headache”, typical of the elderly.
In some patients, as an alternative to painful symptoms, however, attacks of vertigo can be triggered, similar to those of labyrinthitis and equally disabling, which experts define as “migraine equivalent”. In these cases, the discomfort you feel is very similar to that characteristic of seasickness and nausea and vomiting are often also present.
Complications
As with other forms of headaches, the main risk associated with migraine with or without aura comes from inadequate treatments, which can lead to an increase in the frequency, duration and intensity of the migraine attack, resulting in a significant decline in quality of life.
To avoid seeing the disorder worsen, the first and most important advice is not to abuse over-the-counter analgesic and anti-inflammatory drugs. When the headache begins to recur more than 2-3 times a month or persist for more than 3-4 days, you should not insist on “do-it-yourself” therapies (pharmacological or otherwise), but consult your family doctor to obtain a correct classification and start specific therapies.
If migraine appears particularly disabling and difficult to alleviate with prescribed drugs, it is advisable to contact a center specialized in the treatment of headaches in order to access an evaluation by a neurologist expert in this field, who can indicate the best analgesic strategy (ie aimed at reducing or eliminating pain) for the management of acute attacks and, In case of chronic migraine, appropriate preventive therapy to reduce the frequency of episodes.
Migraine treatments with aura
There are no specific therapies to manage migraine with aura: both in terms of the treatment of episodic acute attacks and on that of the prevention of their recurrence in chronic forms, the pharmacological approaches used are the same as those provided for migraine without aura.
In particular, if a few seizures appear a year, therapy is aimed at alleviating the symptoms of acute attack, first of all pain. To do this, in the first instance, you can use common analgesics or non-steroidal anti-inflammatory drugs (NSAIDs) over-the-counter, freely available in pharmacies without the need for a prescription. If their intake takes place from the onset of headaches, these remedies, in many cases, are sufficient to quell the discomforts of the attack effectively and safely.
When this does not occur, due to a particularly “aggressive” migraine, the doctor may prescribe more specific anti-migraine drugs such as triptans, in use for several years all over the world and characterized by high efficacy against this form of headache, with good tolerability. An essential aspect to consider in case of treatment with any triptan concerns the timing of intake: to be sure of obtaining the desired analgesic effect, the drug should be taken at the beginning of the painful phase because, if administered too soon (ie during the aura), it is no longer able to counteract the pain that will appear later. Triptan-based drugs are available in different formulations, from tablets to nasal spray.
Another class of drugs useful against moderate-severe migraine is that of ergot derivatives (a fungus from which alkaloids are extracted), which act on brain circuits that use dopamine as a neurotransmitter (the same ones that function in a deficient way in Parkinson’s disease), enhancing them. However, the use of active substances of this class is limited by possible long-term side effects (induction of fibrosis in the heart, lungs and other organs present in the abdomen) and their use should be weighed on the basis of a careful risk-benefit balance.
One promising treatment for migraine, although still being tested, appears to be transcranial magnetic stimulation.
If migraine pain, preceded or not by aura, often recurs, for a total of more than 12-15 days per month, for periods of at least six months, the possibility of starting migraine prophylaxis therapy, aimed at reducing the frequency and intensity of attacks, should be considered. In this case, to set up a correct and as effective preventive therapy as possible, you should contact a neurologist specialized in the treatment of headaches. The main classes of drugs that can be proposed by the doctor in this case include active ingredients against hypertension and depression, anticonvulsants, monoclonal antibodies (for example against the Cgrp receptor) and botulinum toxin type A (administered by subcutaneous injection).
Especially in migraine forms associated with psychophysical stress, in order to prevent attacks, cognitive-behavioral therapy approaches, acupuncture and relaxation techniques of various types (yoga, guided breathing, massages, etc.) can be exploited which, thanks to the easing of emotional and intellectual tension, also have a positive effect on well-being and general health.
When to consult your doctor
When they appear for the first time, the symptoms of migraine aura must be brought to the attention of the doctor, who may prescribe some instrumental investigations, such as the evaluation of the fundus and / or CT or brain MRI, to exclude the presence of pathologies other than headache, such as damage to the retina (possible especially if you suffer from poorly controlled diabetes), transient ischaemic attacks (TIA), stroke or other impromptu changes in cerebral circulation, or a neurological disorder.
Performing these in-depth investigations is especially important if the symptoms of migraine aura appear for the first time after the age of 40, in women who have the habit of smoking or who are taking or have been taking hormonal contraceptives for several years, as well as in people of both sexes with specific familiarity for acute cerebrovascular events and, always, in children with moderate-to-severe or frequent headaches or in the presence of headache associated with mental confusion and neck stiffness, with or without the typical symptoms of the aura.
In addition, reference should be made to the doctor or neurologist if the characteristics of the aura change over time, if the migraine pain that follows it is very intense and disabling, if the discomforts associated with the attacks are not alleviated with the analgesics previously prescribed or if their frequency increases to the point of making the headache a habitual companion.
Joycelyn Elders is the author and creator of EmpowerEssence, a health and wellness blog. Elders is a respected public health advocate and pediatrician dedicated to promoting general health and well-being.
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