Migraine Disease From a Different Perspective
According to diagnostic criteria established by the International Headache Society, to be diagnosed with migraine disease, patients must have had at least 5 headache attacks that lasted 4–72 hours and the attacks must have had at least 2 of the following characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by or causing avoidance of routine physical activity
In addition, during the headache the patient must have had at least 1 of the following:
- Nausea and/or vomiting
- Photophobia and phonophobia
We think it is imperative to view migraine as a full-body disorder.
While this is the typical classification for migraine disease, we at AMD recognize that migraine is a complex neurological disease with symptoms well beyond a headache. Migraine can impact the entire nervous system. This means people may experience symptoms in various parts of their body. One may think these widespread symptoms are not related but in fact, migraine could be the underlying cause. Here are some common migraine symptoms that aren't often associated with migraine:
- Imbalance
- Difficulty finding words
- Ear and sinus pressure
- Sleeping poorly
- Feeling anxious
We choose to highlight the spectrum of migraine manifestations. Click here for a full list of possible migraine symptoms.
Migraine Phases
Migraine attacks can progress through several phases, each with characteristic symptoms, varying in severity and duration. While this graph shows it as 4 distinct phases, the symptoms actually overlap significantly. Not all individuals experience all 4 phases and each person’s attack can vary from one to the next.
A unique aspect of a migraine attack is the prodrome and postdrome phases. While a person may not be having a headache in this phase, that may not be feeling or functioning well for hours or days.
Many migraine patients describe their prodrome as the onset of yawning or the feelings of depression, slow thinking or fatigue.
A fifth phase that occurs between cycles is called the interictal phase. It can be an unpredictable length of time and therefore some people struggle with the anxiety of not knowing when to expect their next attack.
Migraine With Aura
Two main types of migraine have been recognized: migraine with and without aura.
An aura is a temporary sensory disturbance before or during the headache. Common auras are the illusion of changes in vision, an unpleasant phantom smell or confused thinking.
While patients often describe an aura where they feel a numbness that starts in an extremity and moves centrally, visual auras are FAR the most common. The “classic” visual aura is a scintillating scotoma - that is, a small central area of temporary blindness followed by brightly colored, shimmering light.
It is helpful to remember that an aura does not have to occur with every headache and about 5% of those with aura never have a headache. The most common of these painless migraine events is an ophthalmic, or ocular migraine. People often mistake this for a transient ischemic attack (TIA) or stroke.
Episodic vs. Chronic Migraine
Episodic Migraine is characterized by those with migraine who have 0 to 14 headache days per month, while Chronic Migraine is characterized by 15 or more headache days per month and 8 or more days must have "migraine-like features."
Established Migraine Types
Vestibular Migraine
This condition may soon be recognized as the most common cause of dizziness. It is distinctive for its wide range of symptoms (imbalance, spinning, ear pressure, and tinnitus), variable duration (seconds to days) and other non-headache symptoms, such as difficulty seeing, intolerance for bright lights and noises, neck pain and spasms, confusion, spatial disorientation and increased anxiety. It mimics the two other common balance disorders, benign positional vertigo and Meniere’s disease. The most recent version of the International Classification of Headache Disorders recognizes vestibular migraine as a subtype of migraine.
Ocular Migraine
An ocular migraine is an episode, usually in one eye, where any of a number of visual distortions can occur for up to about one hour. Thought to be caused mainly by tightening or swelling of the blood vessels in the optic nerve at the back of the eye, there may be other factors at play as well. Often an attack begins with a blind spot in the central area of vision which can start small and get larger. This is often followed by an aura stage with other visual distortions such as what looks like a spot of light moving about in your peripheral and central vision, or a kaleidoscope view. An ocular migraine attack can occur with or without an accompanying headache.
Hemiplegic Migraine
Hemiplegic migraine (HM) is a rare type of migraine where an individual experiences motor weakness on one side of the body, usually accompanied by or followed by a headache. The weakness is a form of aura and is associated with at least one other aura symptom such as visual changes. The weakness is not always on the same side as the head pain and it can vary from mild to severe. HM may affect only part of the body, such as just the hand or both the hand and arm, or just the face. Weakness of the entire side of the body can occur. Severe attacks of HM can occur that may progress to seizure, decreased consciousness, or coma. Most individuals who experience HM also experience migraine attacks with typical aura (without weakness).
Abnormal variations in three genes have been identified as causes of familial hemiplegic migraine. Variations in the CACNA1A gene cause familial HM type 1. Variations in the ATP1A2 gene cause familial HM type 2. Variations in the SCN1A gene cause familial HM type 3.
Migraine With Brainstem Aura
Migraine with brainstem aura is a classification that used to be known as basilar migraine. There is some controversy surrounding this diagnosis and publications vary in regard to its prevalence and its cause/origin.
This type of migraine occurs when aura symptoms are of the type thought to originate from the brainstem, but there is no motor weakness associated with the aura. According to ICHD-3, the diagnostic criteria for MBA is migraine with aura including at least two of the following symptoms: slurred or slow speech (dysarthria), vertigo, ringing in the ears (tinnitus), partial hearing loss (hypoacusis), double vision (diplopia), impaired coordination (ataxia), or decreased level of consciousness.
Migraine Without Head Pain (Silent Migraine)
Those with migraine without head pain experience phases of a migraine, including the aura phase, but do not experience head pain. People with migraine without head pain may experience nausea, visual disturbances, runny nose, dizziness, weakness, brain fog, and others.
Abdominal Migraine
Abdominal migraine is characterized by recurrent episodes of moderate to severe belly pain with nausea, with or without vomiting, in children. Often there is no associated headache. It lasts from 2 hours to 3 days, without symptoms between episodes.
Status Migrainosus, also known as intractable migraine, is a migraine that lasts longer than 72 hours. The symptoms are more severe than a typical migraine and abortive medications are usually ineffective. This condition is very difficult to treat and inpatient hospitalization may be necessary for pain management and for the prevention of dehydration due to nausea/vomiting. Status Migrainosus generally occurs due to ineffective treatment, an adaptation to medication or when abortive medications are taken too late in the migraine cycle.
Sinus Migraine
A study found that greater than 80% of patients presenting with sinusitis met the criteria for migraine disease. It is hypothesized that the activation of the trigeminal-autonomic reflex causes sinus-like symptoms: mid-facial pain, stuffy nose, nasal drainage and loss of smell. The combination of sinus-like symptoms along with the ICHD-3 diagnostic criteria of migraine indicates a likely diagnosis of sinus migraine. It is important that all healthcare providers screen for migraine prior to diagnosing a patient with sinusitis. Sinus pathologies are usually ruled out prior to diagnosis of sinus migraine. The misdiagnosis of these similar conditions can lead to antibiotic misuse as well as unnecessary surgical intervention.
Take the Quiz and See if You May Have Migraine
Migraine Pathophysiology
A detailed look at the current understanding of migraine pathophysiology, including an explanation of new theories in the impact of sex hormones, why migraine mimics sinusitis, the evolution of migraine into a chronic disease and more.