Category: Types

Abdominal Migraine

Table of Contents
  1. How Did It Come to be Called a Migraine?
  2. Symptoms of Abdominal Migraine
  3. What Causes Abdominal Migraine?
  4. Diagnosis of Abdominal Migraine 
  5. Who Gets Abdominal Migraine?
  6. Treatments for Abdominal Migraine
  7. Outlook/prognosis
  8. Additional Resources

Research has proven that migraine tends to pronounce itself in many different forms. However, its impact is felt throughout the body, with its severity and frequency of episodes depending on the patient’s triggers, environment, genetics, and treatment plan. But unlike other types of migraine, abdominal migraine or “stomach migraine” is considered an uncommon type of migraine.

 

How Did It Come to be Called a Migraine?

Abdominal migraine is a type of migraine, but it does not directly involve head pain. Instead of cranial inflammation being the epicenter of the attack, the gut is the epicenter of the attack. The differences don’t stop there- the attack commonly targets the gastrointestinal system, and there are no patterns of consistency.1  Even though it shares some triggers and body-wide side effects of a typical migraine, it is still largely misunderstood. 

 

Symptoms of Abdominal Migraine

Abdominal migraine, given its name, has its root in the gastrointestinal tract. However, it has some overlap with chronic migraine. The most common symptoms associated with abdominal migraine are:

  • nausea
  • frequent bouts of vomiting 
  • loss of appetite
  • pale skin
  • moderate to severe abdominal pain centered around the naval (belly button)

The hallmark symptom of abdominal migraine is that attacks tend to occur with no warning and the abdominal pain severely impacts the patient’s way of life. In addition, symptoms rarely occur outside of the acute attack. Just like any type of migraine attack, the duration can range from several hours to a couple of days.3  Vomiting is more commonly seen in children than adults. 

 

What Causes Abdominal Migraine?

The exact cause of abdominal migraine is unknown. Current research suggests that this type of migraine has to do with the gut-brain connection. Amy Gelfand, MD, Director of the Pediatric Headache Program and Pediatric Headache Specialist at UCSF, explains the connection in greater detail:

Abdominal migraine has similar triggers to other types of migraine, such as:

  • food intolerances (e.g., processed foods, nitrates)
  • motion sickness
  • stress
  • lack of sleep
  • dehydration

Abdominal migraine, just like any other type of migraine, has been studied for its epidemiology: do genetics or environmental factors have more of a determining factor? Migraine is thought to be a more genetic disease, but it is important to consider how big of a role environmental factors play in the development of migraine, especially in children. It is possible for a patient to have a genetic predisposition to migraine, and then, depending on the prenatal and postnatal environment, certain environmental influences could determine how easy it is for the genes for migraine to activate and the rate of their frequencies.1

 

Diagnosis of Abdominal Migraine 

Diagnosing abdominal migraine can be tricky. Abdominal migraine tends to overlap with other gastrointestinal disorders that affect children which can lead to a misdiagnosis in some cases.

Did you know?

Gastrointestinal disorders that affect children include:

  • CVS (Cyclic Vomiting Syndrome) 
  • colic
  • IBS (Irritable Bowel Syndrome) 
  • food intolerance
  • acid reflux
  • constipation

Research has identified two of these possible conditions that are linked to abdominal migraine: CVS and infant colic. 

 

CVS (Cyclic Vomiting Syndrome) 

CVS is characterized as a condition where the patient experiences cyclic, or periods, of extreme vomiting. The periods can range for as long as hours to days. CVS is often a disease that may be difficult to control. This condition is commonly mistaken for other functional gastrointestinal disorders such as acid reflux, irritable bowel syndrome (IBS), constipation, chronic stomach ache, and recurrent abdominal pain. This disorder doesn’t have an exact explanation but is believed to involve the subcortical brain structure, the hypothalamus, which is highly involved in this phenomenon of recurrent severe vomiting spells. The clinically observed explanation is patients with CVS report that vomiting spells tend to occur at night, which can result in poor sleep patterns1.

There are clear differences between abdominal migraine and CVS. While both tend to occur in children and produce periods of vomiting, abdominal migraine is more episodic with small periods of vomiting. Another difference is that the primary symptom of abdominal migraine is unexplained abdominal pain while for CVS is severe uncontrollable bouts of vomiting. 

Current research has evaluated whether CVS in children is a precursor to abdominal migraine. Dr. Gelfand notes that it is possible for a child, diagnosed with CVS, to outgrow their symptoms and then develop migraine symptoms later.1 Dr. Gelfand notes that the likelihood of CVS progressing into migraine is about 50-66% likely. 

 

Infant Colic

Infant colic is a gastrointestinal condition that affects young children aged. Dr. Gelfand characterizes colic as excessive crying from an otherwise healthy and properly nourished infant.3 Infants are commonly diagnosed around two weeks old and the diagnosis typically lasts until three months old. The common yardstick to diagnose colic is Wessel’s criteria. Given the variability of the amount of crying seen in colicky babies, the criteria states a diagnosis of colic involves excessive crying for at least three hours a day, for at least three days a week.3 It is noted that crying tends to occur more during the evening hours. Similar to abdominal migraine and CVS, the exact cause of colic has not yet been determined. 

Researchers, however, have established a possible link between colic and migraine. The theory that surrounds this connection is similar to migraine, colicky infants are more likely to experience overstimulation with their environment. This overstimulation is especially true in infants who have a family history of migraine.3 To lessen the number of episodes of excessive crying, Dr. Gelfand recommends that parents handle the infant similar to how a migraine patient handles their migraine during an attack. This includes limiting the number of triggers in the infant’s environment3: 

  • turning down bright lights
  • allowing a few visitors at a time with the infant
  • making the room as quiet as possible
  • not rocking the infant during an attack (due to motion sensitivity)

As complex as this type of migraine can be, it is not difficult to imagine the frustration that may be experienced when trying to get a proper diagnosis from the right specialist. Even though it is second nature to associate gastrointestinal issues with a gastroenterologist, it is beneficial for an individual who believes they have abdominal migraine to seek an opinion from both an gastroenterologist to rule out any other condition, and a neurologist, given migraine’s relationship to the gastrointestinal tract. While there is no specific diagnostic assessment for abdominal migraine, a physician will conduct the same examination and tests to rule out any other gastrointestinal conditions.

 

Who Gets Abdominal Migraine?

Previous clinical studies have observed the following prevalence of abdominal migraine:

  • About 1-4% of school-aged children are diagnosed with this type of migraine.4
  • Abdominal migraine is more common in girls than boys.5
  • Christopher Oakley, MD, Neurologist at John Hopkins University observes that abdominal migraine is most often seen in children ranging from toddler age to early elementary.2  But a rising number of cases in adults are becoming evident.  
  • It is observed that childhood diagnosis of abdominal migraine is linked to an adult diagnosis of migraine headaches.6
Risk factors

Although there are no risk factors specific to abdominal migraine, there are links to anxiety and depression among patients. During severe spells of vomiting, the greatest risks to an abdominal migraine patient are malnutrition and dehydration. If such occurs, seek medical attention urgently.  

 

Treatments for Abdominal Migraine

Similar to those who are afflicted with other types of migraine, there is a wide range of treatments available that target gastrointestinal symptoms and improve quality of life. 

Given that this type of migraine is seen more in children, it is important for parents or caregivers to identify and understand ways that children, who are not old enough to verbalize their symptoms, express pain and discomfort. 

 

Scott W. Powers, PhD, ABPP, FAHS, CCRF Endowed Chair & Professor of Pediatrics at Cincinnati Children’s Hospital/University of Cincinnati College of Medicine, notes that it is most beneficial for parents to watch their child’s actions before and during an attack; such behaviors might hold insight into symptoms, severity, and early coping mechanisms. Dr. Powers also recommends the following steps for parents to take to support a child diagnosed with abdominal migraine7:

  • think of ways to keep them active
  • be involved in daily activities 
  • seek out professionals who can give a clear diagnosis and clear treatment plan
  • help them develop coping strategies not just during attacks but to their diagnosis
  • provide a safe space for the child to express their feelings

Healthcare providers advise all migraine patients to establish an ACTION plan to manage and treat their migraine. The ACTION plan is broken down into five categories.

 

ACTION Plan

Shin Beh, MD, Founding Director of the Vestibular and Neuro-Visual Disorders Clinic at UT Southwestern, details what he calls his ACTION plan8:

Components of the ACTION plan

A (alternative therapies)

C (changes)

T (therapeutic options)

I  (interictal symptom management)

O-N (planning to move “on”)

Step “A” (alternative therapies)

The first part of developing an ACTION plan is to consider alternative therapies (Step “A”). Alternative therapies include vitamins, herbs, nutraceuticals (a substance that is a food or a part of a food that has medical or health benefits), and exercises that are tailored to the individual. 

 

Step “C” (changes)

Part two of the ACTION plan is to implement changes (Step “C”). This stage of the sequence involves two parts. It is necessary to identify triggers and avoid them in this step. The changes that take place can be little or big changes. Examples of this would be creating a diet that you can stick to or one that is specifically tailored to be anti-inflammatory and avoid food triggers. Another example is modifying one’s lifestyle to avoid known environmental triggers as much as possible. This step can be most challenging in the case of children who attend school. 

 

Step “T” (therapeutic options)

Part three is to explore therapeutic options (Step “T”). This step involves finding preventive and acute medications that fit your symptoms and lifestyle. This step is the step with the most trial and error. This step could be the most frustrating part of the sequence that can span years. Even if a medication is effective, it can become less effective over time, which could lead to searching for a new option.

 

Step “I” (interictal symptom management)

Part four is specifically catered to treating/managing interictal symptoms (Step “I”). This step is the step that requires a dispelling of stereotypes around migraine. The ongoing challenge in managing migraine is a reminder that symptoms are truly more than the sum of their parts. It’s never “just a headache” or “constant belly pain.” Migraine attacks are much more complex than many realize. At this step, it is helpful for parents to help their children manage their self-esteem and coping mechanisms in the face of possible stigma from their classmates, teachers, coaches, etc. Learning to manage migraine symptoms is also the key to preventing other comorbidities (the presence of two or more diseases or medical conditions) that are more likely to occur with a migraine diagnosis, such as anxiety, depression, insomnia, sleep apnea, and motion sensitivity, also known as motion sickness.  

 

Steps “O-N” (planning to move on)

The final part of the ACTION plan is a simple reminder to have faith that things will get better (Steps “O” and “N”). Now granted, that’s easier said than done. While it can seem migraine takes center stage in most people’s lives, it can be managed in a way that it takes occasional precedence. This part of the plan also encourages the need to make steps toward planning a life with migraine, rather than planning life around it. Migraine can be chronic, establishing an optimistic future for yourself (e.g., manageable goals, lifestyle changes, future aspirations) and a solid support system are necessary to navigate through life with migraine.   

 

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy, or CBT, has been an effective therapeutic approach that has been utilized across a breadth of subjects in mental, physical, and emotional health. CBT combines both a cognitive and behavioral focus to develop healthy self-esteem, behaviors, personal coping skills, problem-solving, and regulation of emotions in the face of personal adversity. 

Previous studies have cited a link between abdominal migraine and anxiety.5 CBT can be an effective therapy to use to reduce stress and treat migraine when used simultaneously with drug modalities.

 

Drug Therapies 

Treatment Options for Adults vs Children

Some treatment options are more suited for adults than children. Fortunately, there are a multitude of drugs to combat gastrointestinal symptoms for both groups. Similar to chronic migraine and other types of gastrointestinal disorders, abdominal migraine may be treated with both preventive and rescue medications. 

 

The typical course of treatment for abdominal migraine follows the same trajectory as classic migraine and other chronic gastrointestinal disorders by utilizing various drug modalities. Current treatment options include:

  • supplements
  • tricyclic antidepressants
  • serotonin inhibitors 
  • dopamine inhibitors
  • neurokinin-1 receptor inhibitors 
  • triptans
  • propranolol (Inderal)
  • topiramate (Topamax)
  • over-the-counter anti-nausea medications
  • over-the-counter anti-inflammatories (NSAIDs)

Dr. Gelfand recommends having a go-to first-line treatment, and having at least one rescue option — in case the first-line doesn’t get the job done. She also recommends making the first-line treatment an oral one, and your rescue should utilize another route so the treatment gets into your system to help stop the attack in the event of severe vomiting.1 

Supplements, such as coenzyme Q10, L-carnitine, and riboflavin, can be helpful for both children and adults. The theory surrounding these supplements’ properties is that they help with the mitochondria.1 They are generally well tolerated and have very few side effects. The L-carnitine, however, can leave a fishy aftertaste. 

Tricyclic antidepressants, such as, amitriptyline (Elavil), are used to decrease the frequency of migraine attacks as a preventive option. This branch of antidepressants works to increase the amounts of the neurotransmitters serotonin and norepinephrine. Common possible side effects can be exhibited as dry mouth and constipation. Dr. Gelfand recommends that while a patient is taking tricyclics that their doctor is routinely checking their heart rhythm to ensure that there’s not a lengthening of a part of the heart rhythm called the QT interval.1 The side effect comes in the form of an abnormal heartbeat in mild cases. 

Whilst increasing norepinephrine and serotonin is helpful in increasing blood flow to constricted-prone blood vessels in the brain, increasing the amount of serotonin in the body can also be a double edged sword, especially for abdominal migraine patients.1 So it is a helpful to consider serotonin inhibitors including ondansetron  (Zofran ODT) and granisetron (Kytril) which work to prevent nausea and vomiting by blocking serotonin molecules. Headache and dizziness are usually the main side effects with these types of drugs. 

Dopamine inhibitors, including prochlorperazine (Stemetil, Buccastem) and chlorpromazine (Thorazine), work to block increases of dopamine, which results in vomiting and nausea.1 Migraine and dopamine have a complex relationship: low levels can cause system-wide hypersensitivity to sensory stimuli that migraine patients know all too well. But at high levels, dopamine can cause excess nausea and vomiting spells.9   

Drugs that work on the neurokinin-1 receptors, such as aprepitant (Emend), work in conjunction with other medications, like ondansetron (Zofran ODT), to inhibit nausea and vomiting. Aprepitant works in the area of the brain on receptors involved in vomiting.3 Originally, the drug was intended for chemotherapy-induced nausea and vomiting, but over the years has been used outside this medical situation due to its lasting effects, and can be used as both preventive and acute treatment.1 Aprepitant is generally well tolerated, though it has been observed that patients can exhibit hiccups as a side effect and getting this medication covered by insurance can be difficult due to its status as a novel drug.1 

Triptans, such as sumatriptan and zolmitriptan, are popular alternatives for those who have trouble keeping oral medications down due to severe vomiting spells. Triptans, another form of serotonin receptor inhibitors, work to decrease swollen blood vessels. They come in the form of an oral pill, and are available as a nasal spray. Nasal spray options such as these work by getting absorbed across the lining of the mucosa of the nose, where there are a lot of blood vessels. Nasal spray absorption in the bloodstream can therefore be very rapid are faster than oral drug formats.1 Sumaptriptan is also available as a subcutaneous injection, which is very effective for the same reason as nasal spray options. Both zolmitriptan and sumatriptan are used as rescue medications.3 

Propranolol (Inderal) is a drug that belongs to the treatment class of beta blockers and is used as a preventive in the treatment of migraine. Beta blockers, such as this one, are commonly used as a blood pressure medication that relaxes the blood vessels, which is very useful for migraine patients. 

Topiramate (Topamax) is a common anticonvulsant (seizure) drug that can be used in the prevention of migraine. More specifically, most physicians recommend topiramate as a prevention of abdominal migraine due to a number of patients showing a decrease in symptoms.  

Though the most commonly used over-the-counter anti-nausea medications include Pepto Bismol, Dramamine, and Tums, antihistamines have been cited as a possible remedy for nausea. They work the same way drugs like Dramamine combat motion sickness. Some over-the-counter medications and prescription anti-nausea medications can be utilized as suppositories.  

Over-the-counter anti-inflammatory medications (NSAIDs), like ibuprofen, are common drugs that people use for migraine attacks. But in the case of abdominal migraine patients, they’d be reaching for these medications for their severe belly pain. However, a study has shown that when children in an emergency room setting were randomly assigned to receive either an NSAID medicine, like ibuprofen or ketorolac, or one of the dopamine-acting agents, such as prochlorperazine, those who received prochlorperazine reported higher satisfaction and were more likely to improve over a certain period of time than those who received the NSAID medicine.1 

 

Natural remedies

Even though it seems counterintuitive that certain smells could bring relief to a individual whose sensitivity to smells can cause bouts of nausea and vomiting, it has been cited that certain aromas can make a slight difference. Dr. Gelfand mentions a study conducted in an emergency department setting. Adults with nausea were given different treatments to combat the nausea like ondansetron and smelling alcohol swabs. It was found that breathing in the alcohol swabs smell was actually quite helpful for people’s nausea.1 It has also been cited that the smell of peppermint and lavender oil have provided relief to migraine and nausea patients as well. 

A remedy that has been scrutinized for the treatment of nausea is cannabis. Many people have noted cannabis’ effect on nausea and appetite. However, nausea/vomiting prone individuals are primed for a condition known as cannabinoid hyperemesis syndrome. This effect is especially true for individuals who had cyclic vomiting syndrome or people who use cannabis frequently. Cannabinoid hyperemesis syndrome produces symptoms similar to cyclic vomiting syndrome — episodes of very extreme vomiting — in people who have been exposed to cannabis frequently over time. Dr. Gelfand suggests topical CBD as a good cannabis-based therapy option.1  

The most common natural remedies resorted to for managing gastrointestinal symptoms are ginger chews/drops, refraining from drinking any beverage too quickly, eating smaller meals, keeping hydrated, and following the BLAND diet which is commonly recommended for patients who have severe vomiting and diarrhea. It involves eating bland foods and drinks such as toast, bananas, rice, Jello, and non-spicy foods.1 

 

TENS/Acupuncture 

Acupuncture has been cited as another natural remedy to combat abdominal symptoms. Common examples of over-the-counter acupuncture devices are Sea-Bands and TENS units, which affix to a person’s wrist to divert the pain signals away from the brain. These devices are particularly useful as drug-free alternatives to prescription or over-the-counter anti-nausea medications. This non-medicated method is especially valuable for patients still physically developing such as children and adolescents.1

 

Outlook/prognosis

Life with a chronic disease such as abdominal migraine can be an emotional and physical challenge. The field of migraine research, however, is an ever-changing landscape with advancements being made every year. Abdominal migraine is being studied more now than ever before. It’s not easy to remain hopeful when trying to minimize gastrointestinal symptoms but this is truly a time for hope. 

It is important to utilize the resources that are currently available to you while a permanent solution to abdominal migraine is still being developed. Having abdominal migraine is not a “life minimizing” or “end of life” sentence; although it may feel overwhelming at times of during unrelenting bouts of stomach pain, nausea and vomiting. As long as one takes steps to effectively manage their migraine condition, rally support from loved ones, and educate themselves and those around them, having a good quality of life with abdominal migraine is very possible.

Additional Resources

Rebound Headache

Table of Content
  1. Introduction
  2. What is Rebound Headache?
  3. What causes Rebound Headache?
  4. Who gets Rebound Headache?
  5. What happens when you have Rebound Headache?
  6. How do you know if you have Rebound Headache?
  7. Treatment Options
  8. How soon does Rebound Headache respond to acute treatment?
  9. Why is it important to recognize and treat Rebound Headache?
  10. When to see a healthcare provider?
  11. Bottom line/Conclusion
  12. FAQ Section

Introduction

Rebound headache can be caused by the medication that we’ve been advised to take for migraine disease. It’s a debilitating disorder, with at least 15 headache days per month, and in severe cases, daily migraine attacks. Approximately 1-2% of the world’s population experience rebound headache, yet the majority don’t know they have it and are not informed on how to prevent it.

As an individual’s migraine or cluster or tension headache disease worsens, they may take medication more frequently. This temporarily lessens the pain, but when it wears off, and they again experience headache pain, they may take another dose, which again wears off, and they may take more. The rebound phenomenon develops when this cycle happens over a period of at least three months. The rebound headache is often worse than their original headache disorder because of the increased frequency triggered by the frequent use of pain relievers and other acute medications.11

What is Rebound Headache?

Rebound headache is referred to as medication overuse headache (MOH) by the International Headache Society’s (IHS) International Classification of Headache Disorders. Rebound headache is a term used by many and is perhaps more well-known than MOH. 

Patients taking medication(s) for their primary headache disorder may develop rebound headache, a secondary headache disorder, because of that medication. This generally happens after taking more than the recommended number of doses of acute medications for at least three months.2 

Secondary headache disorders are headaches due to an underlying illness or condition  condition such as sinus infection, meningitis, brain tumor, brain hemorrhage or head trauma, and in this case, medication:3

There are three main categories of primary headache disorders: 

  • migraine 
  • tension-type headache 
  • trigeminal autonomic cephalalgias, such as cluster headache

Rebound headache can happen with any of these primary headache disorders.4

Migraine occurring 15 or more days a month is known as chronic headache or chronic migraine, regardless of whether it’s the medication-induced rebound phenomenon or has developed without frequent acute medications. So by definition, rebound headache is chronic headache, but not all chronic headache is rebound headache.1

Note that the same medications that initially relieve the headache pain can trigger chronic, and sometimes daily headache attacks if used more than the 10 or 15 days per month. See specific guidelines below (Medications and Frequency Thresholds).

Terminology Stigma

Some clinicians and patient advocacy organizations have taken issue with the fact that rebound headache is classified as medication overuse headache or “MOH” by the IHS International Classification of Headache Disorders. They believe the MOH term places a stigma on the individual with migraine disease.

Key Point

A person with migraine disease should not be blamed for using the medication prescribed or recommended by their physician, especially when they have not been informed by their healthcare provider about rebound headache. Often a healthcare provider will say “take this medication as needed.” It’s important to give the right parameters for each individual medication.15

Whereas rebound headache is not a perfect term because it does not indicate the role that medication does indeed play, it’s generally accepted by the medical community, and it does not place undue blame on people with migraine disease.

“Medication Response Headache” and “Medication Adaptation Headache” are alternative non-stigmatizing terms suggested by the Coalition for Headache and Migraine Patients (CHAMP). These terms are not yet widely used, but they more accurately reflect the causal nature of medications in this type of headache.5

History

The phenomenon of rebound headache was first described in the 1930s by physicians with migraine patients who used ergotamine, an early migraine treatment extracted from the ergot fungus. Physicians noted exacerbation of migraine in patients was associated with ergotamine overuse, and improvement occurred after the drug was stopped. 

In the 1970s physicians began noting increased headache frequency in association with barbiturates and opiates, specifically, codeine. 

In 1988 the first edition of the International Classification of Headache Disorders (ICHD) introduced “drug-induced headache” to describe “headache induced by chronic substance use or exposure.” 

Later, when triptans were used for migraine treatment, they were added to the list of drugs that could “transform” episodic migraine to chronic, if used more than 15 days per month. 

In 2004 the ‘“medication overuse headache” and “MOH” terms were first introduced to describe the disorder, along with acute medication and frequency thresholds that existed.6 7 

What causes Rebound Headache?

Medications and Frequency Thresholds

15 Days Per Month 

Taking only over-the-counter (OTC) medications, for 15 days per month, to relieve migraine pain will trigger this chronic/rebound headache condition. 

The OTC non-steroidal anti-inflammatory drugs (NSAIDS) and analgesics are pain relievers that fall into the 15-day-per-month threshold. Ibuprofen, naproxen (Aleve), aspirin, and acetaminophen (Tylenol) are just a few in this drug class. 

Since these OTC medications are readily available without the need for a prescription, and are relatively inexpensive, it is easy to unknowingly trigger a rebound headache. Although they may temporarily lessen or relieve the pain, more medication is often required to treat increasingly frequent attacks as the primary headache disorder worsens. This can lead to a vicious cycle of rebound headache. All anti-inflammatories and analgesics can potentially trigger rebound headache when used 15 days per month.1 2 

10 Days Per Month

Triptans are another common class of drugs used to treat migraine. These include brand names such as Imitrex, Relpax, and Zomig, and can transform migraine to chronic/rebound with 10 or more doses per month. Since these are prescription drugs, physicians and insurance companies generally won’t approve a number high enough to cause rebound headache. However, patients may have extra tablets from months when they experienced fewer migraine attacks. Without being informed about the phenomenon of rebound headache, taking 10 or more doses in several consecutive bad months could unwittingly trigger this condition. 

Ergotamine was the first migraine medication associated with rebound headache when taken 10 or more days a month, and is still in use today. 

Multiple drug classes, including over-the-counter Excedrin, or use of triptans, along with NSAIDs or analgesics, can trigger rebound headache at 10 days of usage per month.1 2

Key Point

Few individuals with frequent migraine are taking just a single acute medication. When taking some days of triptans and some days with combination analgesics and some days with nonsteroidals, it’s probably best to assume that if one is taking 10 or more days of acute treatment per month — putting barbiturates and opioids aside — that one is likely to get medication overuse headache and transformation into chronic migraine.1

1 or 2 Days Per Week 

Opioids and barbiturates are most likely to cause rebound headache when taken for relief of migraine pain. They are also highly addictive. Fioricet and Fiorinal are brand names for medications containing barbiturates as well as other pain medications. Just one day per week of barbiturate use, or two days of opioid, regardless of the type of opioid, are associated with high-frequency rebound headache. These subtypes of rebound headache are extremely debilitating and difficult to treat.1 2 11 

No Threshold

Almost all acute medications used to treat migraine disease can cause rebound headache.1 

One exception is dihydroergotamine or DHE. This particular derivative of ergotamine is used by injection or nasal spray to terminate migraine. Most headache specialists believe it does not cause rebound headache.1 

Another exception is the newer group of medications, the gepants.  Gepants include ubrogepant (Ubrelvy), and rimegepant (Nurtec), which do not appear to cause rebound headache. In fact, in a one-year rimegepant trial, more frequent doses of rimegepant resulted in fewer migraine days. The study showed that gepants work acutely for attacks, but also can be used preventively for migraine.1 10 

Other Drugs 

Other substances and drugs can contribute to rebound headache for those individuals with an existing primary headache disorder. These include:1

  • caffeine at 100 or 200 milligrams per day
  • over-the-counter decongestants
  • over-the-counter antihistamines (not including newer ones like cetirizine (Zyrtec)
  • benzodiazepines (anti-anxiety agent such as Prozac) – are thought by some clinicians to trigger rebound headache
  • amphetamines
  • sleeping pills – most can trigger rebound headache
  • lasmiditan (REYVOW) – a new drug, is a selective serotonin agonist. Preclinical studies suggest that it may trigger the rebound phenomenon similar to the triptans.8
  •  

Who gets Rebound Headache?

Prevalence

Did You Know?

The estimates vary, but approximately 1%-2% of the general population have rebound headache. That makes it about as common as epilepsy. It’s an extraordinarily common phenomenon.2 Worldwide, only 10% of people that experience rebound headache are professionally diagnosed.16 

Risk Factors

The following are risk factors for developing rebound headache:1 9

  • High frequency episodic migraine – eight to 14 migraine days per month.
  • Migraine that doesn’t respond to various acute medications.
  • Comorbidities – a person with other pain disorders, such as arthritis, fibromyalgia or pain due to injury, in addition to their primary migraine disease.

In these situations, a person with migraine disease is more likely to take frequent medications to relieve headache and/or other pain over a period of months, resulting in triggering rebound headache.

In addition:

  • The use of opioids or barbiturates (Fioricet, Fiorinal) for pain relief poses a strong risk for developing rebound headache. Taking these drugs for just one or two days a week often triggers rebound headache. Additionally, these drugs are addictive which makes them easy to overuse.

What happens when you have Rebound Headache?

Physiological changes

Neurology experts do not yet understand all the pathophysiology associated with rebound headache. It’s believed that over time, when taking acute medication for headache, the brain starts to think this is part of the normal chemistry, and it upregulates receptors for those drugs. When that drug isn’t present, perhaps after a long night’s sleep, the brain thinks that something is missing. The brain communicates that with pain. Taking more medication relieves the pain temporarily but doesn’t treat the underlying disorder.3

How do you know if you have Rebound Headache?

Symptoms

Generally, you experience a pattern of starting with relatively frequent migraine symptoms (eight to 14 days per month), taking an acute medication to get headache relief, obtaining the relief, and then over time the pattern becomes one of increasing headache frequency and increasing medication usage, with headache reoccurring when the dose wears off.  It’s common to wake with head pain in the early morning hours. In this scenario, once you have exceeded 15 migraine days per month for three months, you have likely developed rebound headache.2

Rebound headache symptoms vary. It doesn’t matter if the head pain location is front, back, right, or left side. It can be mild, moderate, or severe. It’s not the type of headache symptoms, it’s the number of headache days. It must be 15 or more headache days per month according to the International Classification of Headache Disorders’ criteria. And there must be the frequent use of acute medications for at least three months.1 

Threshold for Triggering Rebound Headache
FrequencyDrug ClassesExamples
15 days/month NSAIDS and AnalgesicsOTC pain relievers including naproxen (Aleve), Ibuprofen, aspirin, acetaminophen (Tylenol, Paracetamol)
10 days/monthMultiple drug classes or any combination of multiple classes without exceeding the threshold for any one particular drugExcedrin (acetaminophen, aspirin, caffeine)
Combination of triptans and NSAIDS or analgesics
10 days/monthTriptanssumatriptan (Imitrex), Relpax, zolmitriptan (Zomig)
10 days/monthErgotamineErgomar
2 days/weekOpioidsHydrocodone, Oxycodone, Codeine
1 day/weekBarbituratesButalbital, Fioricet, Fiorinal
Table depicts medication thresholds when used for at least 3 months, regardless of dose.

It’s important to maintain a headache diary or calendar to track the number of days you are experiencing migraine symptoms, along with the acute medications that you are taking each day. It can be as simple as noting this information on a calendar, or downloading a free app on your smartphone. This will prepare you for partnering with your doctor to accurately diagnose and treat the disorder.1

Diagnosis

Your doctor can diagnose rebound headache based on your history of a primary headache disorder, recent headache frequency, and medication use. Tests are usually not necessary. Your headache calendar records will be extremely helpful.1 

Treatment Options

Prevention

The typical recommendation is to limit acute medications for migraine to no more than two, or at most, three days per week and avoid opioids and barbiturates. This plan of action will generally prevent rebound headache.

Headache specialists often tell their patients, “This medication will work best if you take it early in your attack. Try to take it while your pain is mild, but don’t take too much.” In reality, that can be difficult to adhere to. Patients trying to avoid rebound headache often delay treatment that may make their disease harder to manage long term.2 

Taking steps to reduce headache frequency by combining different types of preventive methods are key. Partner with your physician to determine which may work best for you. These include:1 2 11 12 15

  • Education regarding migraine management.
  • Lifestyle changes – adequate sleep, regular meals, staying hydrated, exercise, and reducing stress.
  • Behavioral methods including Cognitive Behavioral Therapy (CBT) to help identify and avoid headache triggers.
  • Physical therapy, massage, chiropractic treatment, especially for those with comorbidities such as back pain, fibromyalgia, and arthritis.
  • Neuromodulation device therapy.
  • Preventive medications.
    • Preventive medications include several varieties that are taken on a daily basis. 
    • Botox or the CGRP monoclonal antibodies can be used to reduce headache frequency.
    • The gepants are offering much hope for use as both preventive and acute treatments without triggering rebound headache.10

Acute Treatment

”The most important treatment is education of the patient. If you came in to see me and you had this problem and you were using Excedrin 6 [days] a week for a year, and I explained to you what you’re doing wrong and I said to you, I need you to come off. You can stop it tomorrow. You can stop it over a 2-week period. It doesn’t really matter. You’re going to feel worse for a little bit of time. At the end, you’ll feel at least the same and most probably better, and then I’ll have other medication for you to try as well. If you buy into that and you do it, I think that you’re going to get better.”11 
Alan Rapoport, MD

Breaking the cycle of rebound headache requires restricting your pain medication. The process to do that depends on the types of medications you’re taking. Your doctor may recommend stopping the medication right away or gradually reducing the dosages. They may recommend adding or changing preventive treatments.

Most people with rebound headache are able to eliminate their acute medications with some increased pain, but fairly easily, once they understand the goal and why it’s necessary.11 15

For some people, rebound headache becomes such a trap that medication withdrawal has to be done in the hospital or in an outpatient center under close supervision of a headache specialist. Protocols are in place for keeping the patient comfortable using intravenous therapies until any withdrawal symptoms have disappeared and the process is complete.  That can be necessary if, as medication is withdrawn, severe pain results, or the patient is unable to stop their acute medications.2 

Inpatient treatment provides particular value to the 30% of patients experiencing depression as a result of rebound headache. The frequent headaches make people feel hopeless and helpless, unable to escape the downward cycle. If discharged and headache-free for the first time in years, that often relieves those hopeless feelings.2

The recent availability of the gepants offers promise, and already significant success, for prevention and acute treatment of rebound headache, eliminating what could otherwise be a difficult withdrawal period. 1 10

How soon does Rebound Headache respond to acute treatment?

Overall prognosis for recovery

The majority of patients with rebound headache are able to stop using their acute medications which typically breaks the cycle within a few weeks.  

Patients that struggle most with medication withdrawal and require intravenous therapies usually see a quick improvement. However, the relapse rate is typically 25% within the first year. It’s important to be vigilant with effective preventive treatments to keep from falling back into the rebound cycle. It’s also important to partner with a headache specialist to ensure you are on the preventive treatments that work for you. If something doesn’t work for you, be willing to keep trying until you find effective therapies.2

Why is it important to recognize and treat Rebound Headache?

Key Points

The problems with frequent use of the acute medications are not just the headaches and the worsening of the headaches. These medications can cause a lot of associated medical problems. 

  • The anti-inflammatories and the combination analgesics are not so benign when taken frequently. They can cause:
  • ulcers
  • exacerbation of blood pressure problems
  • kidney dysfunction
  • Though frequent triptan use can cause rebound headache, it’s not generally a problem in terms of overall health.1
  • Opioids are narcotics that alter the pain regulatory system. Use of opioids in migraine patients worsens overall health including frequency of headaches, cardiovascular health, depression, and anxiety. 
  • Butalbital, a potentially dangerous barbiturate, causes sedation. Withdrawal from butalbital can cause seizures. People may be at risk when they’re not aware they’re at risk. It can cause cognitive problems, as well as exacerbating depression. It’s been withdrawn from most markets worldwide including Europe, South America, Asia, and most of Canada, however it’s still available in the U.S.1

When to see a healthcare provider?

If you suspect you have rebound headache, and are experiencing more than two headaches a week, you will need to partner with your primary physician or headache specialist to officially diagnose and put together a treatment plan. The treatment to reduce your need for acute medications by reducing the frequency of your headache days will vary based on the medications you have been taking and your health history.1 11

”If you’re taking more than two days [per week] of acute pain medication for anything, maybe you’re not taking it just for your headache, you’re taking it for something else, I would seek medical attention and try to find out are there different strategies that work for you that you can do that gives you the relief that you need to carry on and have a high quality of life.”15
Larry Charleston IV, MD
Tweet

Bring your headache diary/calendar to your appointment. Come prepared to talk about your headache symptoms, frequency, and any other pain history.1 11

Bottom line/Conclusion

  1. Inform yourself about migraine disease. Keep up-to-date with new treatments being offered. Partner with your physician and take control of your disease.
  2. Seek out a headache specialist, especially if you feel trapped in a cycle of frequent migraine days. Partnering with a headache specialist will ensure you are getting the best treatments, including the newer migraine-specific drugs if appropriate. Note that not all neurologists are headache specialists so be sure to check credentials. 
    1. Find a Migraine & Headache Specialist | AMF (americanmigrainefoundation.org)
    2. Healthcare Provider Finder | National Headache Foundation (headaches.org)
  3. Do not give up. There are many preventive treatments. Keep trying until you find what works for you. The last few years have finally brought forth migraine-specific CGRP and gepants medications. Consider lifestyle and other non-medication preventive options.
  4. Know that you aren’t alone. There are one billion people with migraine disease world-wide.14 You can find support through your local or national migraine patient advocacy organization. 

FAQ Section

 

Ocular Migraine

Table of Contents
  1. What is Ocular Migraine?
  2. What Causes Ocular Migraine?
  3. How Does Ocular Migraine Differ From Retinal Migraine?
  4. Ocular Migraine Triggers
  5. Which Specialist to See When Experiencing Visual Symptoms?
  6. Treatments for Ocular Migraine
  7. Migraine Prevention
  8. Other practices/treatments that may be helpful
  9. Looking forward

What is Ocular Migraine?

Anyone who has ever experienced an ocular migraine can probably recall their very first episode. They might have been sitting at their desk, feeling perfectly normal, then suddenly started seeing flickering lights, zigzagging lines, or a rash of colorful, kaleidoscopic waves. To say that the experience can be alarming would be an understatement. The good news is: it’s not dangerous.

Some people experience these “light show” symptoms regularly, usually before the onset of a painful headache. Others experience the symptoms alone – without the accompaniment of a classic migraine headache. And some may have experienced them only once or twice, never to be repeated again.

Symptoms

Ocular migraine is a term commonly used to describe certain visual disturbances associated with migraine. The symptoms are varied and can include:

  • flashing lights, or kaleidoscope- or prism-like visual sensations
  • zigzagging lines
  • stars
  • blind spots or scotomas

The condition – a type of migraine with “aura” – can be disturbing, but symptoms are generally benign and most last less than an hour. 

Aura is a term that refers to sensations other than head pain that can accompany a classic migraine. Visual symptoms are the most common type of migraine with aura, though aura can affect other senses and cause symptoms ranging from numbness and tingling in various parts of the body, nausea and vomiting, or even altered motor and language skills. 

These visual disturbances usually affect both eyes and can occur with or without a headache. 

Approximately one-third of migraine patients will experience migraine with aura. Some may have only one or two in their life, others may have a couple a month, and some may have an aura with every attack. About 15% of individuals who experience aura have one with every attack.1

Terminology Confusion

The term “ocular migraine” is considered a misnomer, in that the visual disturbances associated with it occur in the brain, not in the eye or in the retina.  

Though many people – including some medical specialists – continue to use the term “ocular migraine” to refer to a migraine with visual disturbances, it is more accurate to refer to ocular migraine as “migraine with aura” or “migraine with visual aura.”

Ocular migraine is sometimes referred to as “retinal migraine,” and although some of the symptoms overlap, the two diagnoses are not the same. Retinal migraine is a different and much rarer type of migraine.

On occasion, ocular migraine is also called “visual migraine,” “ophthalmic migraine” or “eye migraine,” but these are vague, general terms that refer to any migraine displaying visual impairments. 

But ocular migraine, I don’t use that term at all, because it’s too confusing. I don’t know if the person is talking about retinal migraine or migraine phenomenon or migraine with aura, so we try to stick with migraine with aura and and get rid of ocular migraine or eye migraine, because it really isn’t specific. It’s kind of a slang term.2

What Causes Ocular Migraine?

Ocular migraine – or migraine with visual aura – is generally thought to be caused by electrical disturbances in the brain, triggered by a phenomenon called cortical spreading depression. This refers to electrochemical waves that spread slowly across the cortex, the outer surface of the brain. Most of the time, these disturbances occur in the occipital lobe, the part of the cortex that controls vision, causing visual symptoms.1,2

How Does Ocular Migraine Differ From Retinal Migraine?

Though the terms “ocular” and “retinal” migraine are frequently used interchangeably, the two are not the same. While both types of migraine generally involve unusual temporary visual phenomena, ocular migraine symptoms generally involve both eyes. Symptoms can occur with or without a headache.  

Retinal migraine is a very rare cause of temporary vision loss in one eye (monocular), and can be – but is not always – followed by a headache within an hour of the onset of symptoms. 

The transient vision loss experienced in retinal migraine can range from partial to full. Symptoms may include flashing lights and scintillating blind spots. 

A retinal migraine diagnosis is made only after excluding other possible causes of single eye vision loss. An eye doctor should be able to make the diagnosis after conducting a comprehensive eye exam with dilation, including a formal visual field exam.

Vision impairment is quite common during migraine, so it’s not surprising that they’re going to end up in an eye doctor’s office…

Ocular Migraine Triggers

Ocular migraine attacks can be triggered by the same symptoms that trigger other migraine attacks and vary from person to person. Common triggers include:

  • stress
  • weather (including excessive heat or barometric pressure changes)
  • alcohol (including red wine)
  • caffeine 
  • skipping meals
  • certain foods (including aged cheeses, or foods containing additives such as nitrates, MSG, or artificial sweeteners)
  • dehydration
  • family history of migraine
  • hormonal fluctuations
  • loud noises
  • bright lights, including sunlight
  • strong odors
  • lack of sleep

Additional triggers may include activities that involve:

  • eye strain
  • extended computer screen use
  • harsh lighting
  • long-distance driving

Which Specialist to See When Experiencing Visual Symptoms?

A person experiencing visual disturbances, such as flashing lights, zigzagging lines, or even blind spots may first go to an eye doctor, who can conduct a comprehensive eye exam with dilation and rule out other causes of the symptoms before diagnosing migraine. An ocular migraine diagnosis does not mean the symptoms are occurring in the eye or caused by some dysfunction of the eye. The visual activity is caused by electrical disturbances in the part of the brain that controls vision. These symptoms can occur with or without headache. Patients who experience these symptoms are generally referred to a neurologist for ongoing migraine management.

When to Seek Immediate Medical Attention

Because a number of migraine-related symptoms can affect vision, it is not always easy to determine which are unrelated, but persons experiencing the following should seek medical attention right away to rule out stroke or another diagnosis that could lead to irreversible vision loss:

  • Any significant change or increase in duration of usual visual symptoms.
  • New floaters or flashes of light or dark spots in one eye that do not go away within an hour. 
  • Episodes of temporary vision loss in one eye.
  • Vision loss that presents as darkness or complete blindness.
  • Experiences of tunnel vision or inability to see out of one side of one’s vision field.

Treatments for Ocular Migraine

Drugs that treat regular migraine symptoms may be used to treat ocular migraine attacks. These include over-the-counter pain relievers, including:

  • ibuprofen
  • acetaminophen
  • aspirin 
  • naproxen

Prescription medications that may be used to treat an ocular migraine include many of the same medications used to treat classic or common migraine attacks, such as:

  • triptans, such as sumatriptan (Imitrex) or rizatriptan (Maxalt)
  • ergotamine derivatives, such as DHE (dihydroergotamine)
  • CGRPs – calcitonin gene-related peptide receptor agonists/gepants (Nurtec, Ubrelvy)
  • ditans – lasmiditan (Reyvow)
  • prescription NSAIDS, such as diclofenac or celecoxib
  • anti-nausea medications
  • neuromodulation devices, such as Cephaly, Nerivio, or Gammacore

Whether an individual is using over-the-counter or prescription medication, early-onset treatment is more effective than waiting until after the migraine attack has had a chance to build up.

Migraine Prevention

Patients who experience more frequent visual aura symptoms may consider medications designed to prevent classic or common migraine, including:

  • antidepressants, such as amitriptyline (Elavil ), nortriptyline (Pamelor), or venlafaxine (Effexor)
  • blood pressure medications, such as beta blockers or calcium channel blockers
  • anti-seizure drugs, such as valproic acid (Depakene, Depakote) or topiramate (Topamax, Qudexy XR, or Trokendi XR)
  • monoclonal antibodies, such as erenumab (Aimovig), galcanezumab (Emgality), fremanezumab (Ajovy), eptinezumab (Vyepti)
  • gepants, such as atogepant (Qulipta), rimegepant (Nurtec ODT)
  • Botox

Other practices/treatments that may be helpful

  • Get regular exercise – any kind – including walking, swimming, bicycling.
    • Eat regularly – try not to skip meals.
  • Develop good stress management strategies.
  • Consider mindfulness practices, such as meditation, tai chi, yoga, etc.
    • Maintain a regular sleep pattern (7-9 hours per night).
    • Consider testing for apnea if sleep is frequently interrupted.
    • Ask your healthcare provider if supplements may be helpful.
    • Join a migraine support group for tips and fellowship.
  • Consider FL-41/tinted lenses, which help block color wavelengths that bother persons with light sensitivity.

Looking forward

Roughly one-third of people with migraine experience some kind of aura, and many of those experience some kind of visual aura. The symptoms can be unsettling, but they are generally benign. It is important to note that effective options are available to treat attacks and help prevent future ones, as discussed above.

While there is no cure for migraine, many new treatment and prevention options are now available – and more are in the pipeline. Work with an experienced healthcare professional to find what management techniques work best for you. And consider joining a migraine support group to help you on your healthcare journey.

Migraine With Aura

Table of Contents
  1. What is Migraine With Aura? 
  2. Types of Migraine with Aura
  3. Migraine With Aura Symptoms
  4. Aura Phase
  5. Can you have a migraine without headache or an aura without headache?
  6. Migraine With Aura Causes
  7. Migraine With Aura Diagnosis
  8. Migraine With Aura Treatment
  9. Migraine With Aura Prevention
  10. What about other visual phenomena noticed by people living with migraine?
  11. Migraine aura later in life
  12. White Matter Lesions Associated with Migraine with Aura
  13. Patent Foramen Ovale and Migraine
  14. Risk of Stroke
  15. When to see a healthcare provider?

Migraine, and migraine with aura, is more than just a headache. In fact, for many people it’s not a headache at all. Bouts of vertigo, waves of nausea, vision loss, and the inability to speak or walk are just some of the symptoms that those with migraine with aura can experience.

What is Migraine With Aura? 

Aura occurs due to a spreading electrochemical event on the surface, or the cortex, of the brain. This electrochemical event spreads slowly, two to three millimeters per minute, across the cortex, and as this event progresses, the aura symptoms commence. 

Most of the time, 90% in fact, the aura begins in the occipital cortex which controls vision, explaining why patients often complain of hallucinations in their vision. They’ll see spots, sparks, stars, lightning bolts, or even colors or prisms that will grow. Oftentimes it starts in the periphery, but it can also begin in the center of the vision. Then it expands over a period of time. The International Headache Society classifies migraine with aura as having reversible symptoms that resolve within an hour. If it goes on longer than an hour, that’s called prolonged aura and is less common.1,5 

The duration of symptoms depends on which area of the brain the spreading electrochemical event is occurring. Some people may start to feel numbness in their tongue, in their face, in their hand, in their arm, or even in their leg. They may think they’re having a stroke. Sometimes people will develop a language aura, so they’ll not be able to find words, or express themselves properly. They may slur their speech, or they might not understand speech (also known as aphasia). The type of dysfunction experienced corresponds to the physical part of the brain involved during the migraine attack. There are different types of symptoms, but they usually happen for a short period of time, and should be fully reversible.

Approximately one third of migraine patients will experience migraine with aura. Among those with aura there is great variability. Some may have a couple of auras in their life, others may have a couple of auras a month, and others may have an aura with every single attack. Of those individuals with aura, about 15% will have an aura with every attack. 

Types of Migraine with Aura

1. Migraine with typical aura

Migraine with typical aura refers to the most common symptoms associated with aura such as numbness, weakness, trouble with language, and visual disturbances. In addition to this combination of symptoms there are other types of migraine with aura with their own set of symptoms although some overlap with typical aura is common. 

2. Migraine with brainstem aura

In migraine with brainstem aura, a distinct set of symptoms can be experienced and produced by the brainstem itself which sits underneath the hemispheres of the brain.

Individuals may experience double vision, slurred speech, unsteady gait, dizziness, vertigo, ringing in the ears, or tingling on both sides of the body. 

With all these symptoms an individual may have one, some, or all of them during a migraine attack.2

About 10% of those who experience migraine with aura will have migraine with brainstem aura. It’s more common than hemiplegic migraine, but it’s still not common.2

3. Hemiplegic migraine

Hemiplegic migraine can cause paralysis and/or weakness. The name “hemiplegic” comes from the fact that during the aura or the neurological symptoms that precede the migraine attack, the patient is weak on one side of the body hence the term “hemi” meaning half and “plegia” meaning weakness.

Clinicians should determine if patients are describing numbness when perhaps they actually mean weakness. For instance, Dr. Dodick, at the 2017 Migraine World Summit, commented, when someone says numbness, “What do you mean by that? Do you mean that there’s no sensation? Do you mean that it’s tingling and prickling, or do you mean that it’s actually clumsy and weak?” It’s a very important distinction.

 Hemiplegic migraine causes weakness, and that weakness can involve the face, the hand, the arm, the leg, or all of the above. When patients with hemiplegic migraine develop weakness on one side of the body, they will almost always have either a visual aura and a sensory aura, and sometimes a language aura. 

Symptoms may include:

  • tingling and numbness
  • visual illusion (visual aura) 
  • they may not really understand what you’re saying or have trouble processing information
  • they may have trouble speaking.2

Hemiplegic migraine patients can present with hemiplegia, or weakness on one side of the body, which can mimic a stroke.

Sometimes there’s a motor aura, where people will develop weakness on one side of their body and that can mimic a stroke as well. 

4. Retinal migraine 

There is a form of migraine called retinal migraine, which is truly in one eye, but it’s an extremely rare form of migraine and it’s very difficult to diagnose.3 

Some of the people who have been examined during what they call a retinal migraine actually have a vasospasm of their artery in their eye causing the visual phenomenon. It’s always in one eye and they can get a headache right behind their eye.

What about ocular migraine?

If patients are experiencing black holes in their vision, spots in their vision or the symptoms of aura without headache, they typically see an ophthalmologist or eye doctor. Fortunately, most eye doctors will recognize migraine and be able to distinguish it from ocular disease. 

Eye doctors may refer to this as “ocular migraine” but it’s not a problem in the eyes itself. Dr. Dodick at the 2018 Migraine World Summit, asked, “Remember the spreading electrochemical event in the occipital cortex of the brain producing those visual symptoms? So ‘ocular migraine’ is a misnomer, it’s not the eyes causing the problem, it’s the brain causing the problem. So we call it migraine with aura whether or not it’s accompanied by headache.”

“Eye migraine” or “ocular migraine” are commonly used to describe this type of migraine but they are technically vague and unclear and not terms used by headache specialists for diagnosis. A headache specialist will refer to the condition either as migraine with aura or retinal migraine – which is a rare condition. 

Migraine With Aura Symptoms

Let’s look at the four phases of migraine and see where the aura phase fits in.

The four phases of migraine are:

  1. Premonitory or Prodrome phase
  2. Aura
  3. Headache phase
  4. Postdrome phase

The premonitory phase refers to the symptoms that occur in the hours before pain begins. 

In the aura phase a variety of symptoms may occur more immediately before the headache phase, but may also overlap with the headache phase. 

The headache phase is the point at which a moderate to severe headache is experienced.  

The postdrome refers to the phase after the headache resolves. Symptoms experienced in this phase may outlast the headache for hours to days.4

Prodrome symptoms

Prodrome symptoms refer to pre-headache signs and symptoms. These include fatigue, yawning, nausea, thirst, irritability and needing to use the bathroom frequently. 

Sometimes symptoms that occur during the painful headache phase itself can occur during the prodrome such as sensitivity to light, sensitivity to sound, neck pain, depression, feeling down, changes in mood, changes in one’s ability to concentrate and to process information. 

You might think, “I’m just in a little bit of a fog today, I’m not firing on all cylinders,” but it could be a prodromal phase. So you can see why all of those things reflect a problem in the brain itself versus in the blood vessels. Blood vessels couldn’t possibly cause all of those symptoms.1

Cravings are another common feature of prodrome cited by patients. These are sometimes interpreted as triggers. Cravings for certain foods like chocolate or other processed foods that are eaten and then followed by an attack lead a person to believe it may be a trigger. That isn’t necessarily the case. It may simply be part of the prodrome. Where migraine is thought to begin in the brain is an area that’s responsible for appetite and could plausibly be causing these food cravings.4

Vomiting and nausea can occur in the prodrome phase but it usually occurs in the head pain phase as the attack has progressed. Oftentimes the nausea is associated with the intensity of the pain, so the worse the pain, the worse the nausea, the more likely you’ll vomit. Not always, but often they tend to track together, but patients can remain nauseated in the postdrome phase, after the head pain has disappeared. 

There’s overlap with these symptoms and phases. There are not always clear lines of division between each phase or its symptoms. 

Aura Phase

Visual symptoms

Visual symptoms are the most common characteristic during a migraine with aura. A visual aura is a discrete neurological event that causes disturbance in the vision. It often will start like a little flickering or kaleidoscopic, and then will build up and grow as it moves across an individual’s field of vision. They are often a warning sign preceding the head pain phase of the migraine.

Many people think something is wrong with their eye, but really it’s happening in the brain, and if they cover the eye that they believe has the problem, they can still see little zig-zaggy lines or spots from the other eye.

We know that this disruption is coming from the brain. We also believe that it is triggered by cortical spreading depression. This refers to an electrical disturbance in the brain.

There are other types of auras, such as dizziness or vertigo auras, or numbness around the face and hand followed by a headache, but the visual aura is the most common.3 

Other visual symptoms include blurred vision, blind spots (scotoma), and/or temporary loss of vision as part of their migraine with aura.

For both living with migraine with and without aura, visual sensitivity in between their attacks is common. This sensitivity extends beyond just light but includes visual sensitivity to stripes, flickering lights and lights that are moving. In those people who are vulnerable, peripheral movement in the visual field may sometimes even trigger a migraine. Bright lights could trigger a migraine. People with migraine, in general, are visually sensitive and this can continue between attacks.3

Sensory symptoms

Numbness or tingling are common sensory symptoms that can occur during the aura. 

Most of the time, people will experience numbness or tingling that begins in maybe a couple of fingers, or maybe the digits of the hand, and then it will gradually creep up to involve the hand, and then maybe move up to the arm. It can jump to the face and occur around the mouth. Sometimes it will go inside the mouth and involve the gums and the tongue. Sometimes it will involve the whole body.

People can also experience weakness during the aura phase. Weakness can occur in the arm or leg, and face drooping can also be associated with their attacks. 

Cognitive symptoms

People may be cognitively affected during a migraine attack. A recent study has shown that cognitive symptoms were the second most disabling symptoms behind the head pain itself.2

Brain fog is a common cognitive symptom. An individual might just feel off on a particular day and not really understand why they feel off. Particularly, if they have frequent migraine attacks. Even though they’re not experiencing a headache, they might normally associate that with headache, but it looks like that symptom clears up, that brain fog clears up when they’re effectively treated.

Dr. Dodick has been seeing this for many years, when a patient is effectively managed on a preventive regimen, they feel better. They feel better because they’re not having as many headaches. “Even when I’m not having a headache, I feel better. I feel like a cloud has been lifted, or a fog has been lifted.”2

Like many symptoms of migraine, they can occur alone or in combination with other symptoms. As you know, you don’t even need to have headache, to have migraine. Dr. Dodick refers to it like a wheel with multiple spokes, and each spoke is a symptom.

Sometimes you’ll have one spoke. Sometimes you’ll have five spokes. Sometimes you’ll have all the spokes on the wheel. 

You can get dizziness, or vertigo associated with a typical migraine attack, which accompanies a headache, and sometimes not. It can occur in isolation or it can occur in conjunction with other migraine symptoms, like sensitivity to light and noise and nausea. 

Can you have a migraine without headache or an aura without headache?

Yes, it is possible, however it is rare to only ever have a migraine aura without headache. This type of migraine is referred to as acephalgic migraine attacks. 

Another term used to describe this type of migraine is silent migraine. It occurs in perhaps 3-4% of people living with migraine. 

Some of the people who have migraine headache and have a visual aura can sometimes only have the visual aura without their usual headache. This combination is more common.

Migraine With Aura Causes

There are different theories but the truth is scientists still don’t really know what causes migraine with aura. One risk factor is having one or two parents with migraine with aura. There is a genetic link.  We do know that it occurs in the brain after it is triggered.

After head trauma, we know that there can be massive changes in depolarization in the brain, but there are people sitting normally, having a depolarization in the brain. The cortical spreading depression seems to occur for no good reason.

There may be certain migraine triggers for some people that make them more susceptible, for instance if they haven’t slept enough. Altitude may play a role in making people more susceptible to aura. But the initiation point is not really known.

Migraine With Aura Diagnosis

Diagnosis is typically made by a clinician taking a history from the patient who describes their symptoms. Some clinicians may perform a physical exam to rule out other conditions. Scans and tests are not typically required but may be requested in certain cases. 

Migraine itself is defined by the International Headache Society criteria as a headache which can be of moderate to severe intensity. It can be on one side of the head or on both sides of the head, and it has certain features associated with it. 

The features, for example, include nausea and/or vomiting; light and sound sensitivity; and difficulty in moving. These symptoms are common with migraine without aura.

Migraine with aura often has those features as well, but has separate features that clinicians can diagnose from listening to patients tell them about visual symptoms of flashing lights, numbness or tingling in the face or hands, and trouble with articulation and understanding others’ speech.   

Migraine With Aura Treatment

We know that early intervention, not just in migraine but other headache disorders and other diseases, help to prevent the downstream effects. The prodrome or premonitory phase sets itself up as an ideal opportunity for early intervention, with treatments that are safe and well-tolerated.

If people recognize the premonitory or prodromal phase they may be able to more effectively prevent or reduce the downstream effects, the onset of the pain and all the other symptoms. 

Once the headache phase begins, many people will reach peak headache intensity within about 30 minutes, so there isn’t a large window of opportunity within which to intervene.2

Acute treatments are medications used to treat an oncoming migraine attack. These include:

  • pain relievers available over the counter, including acetaminophen, ibuprofen, naproxen, diclofenac, celecoxib oral solution, and aspirin
  • triptans such as sumatriptan or rizatriptan
  • ergotamine derivatives such as DHE (dihydroergotamine)
  • anti-nausea medications
  • gepants (Nurtec)
  • ditans (Reyvow)
  • devices (Cefaly, Nerivio, Gammacore)

Triptans are specifically designed to be taken when you have a migraine attack. 

“There was initially some suggestion to say that you should avoid triptans during an aura. There’s a myth there that it’s dangerous to take a triptan during aura because you’re going to cause a stroke.5 There’s no evidence for that. There was one — an older study — that suggested it wasn’t effective. Then there’s also been other studies that suggested it can be effective. So I actually tell people to take it as soon as they feel the onset of their migraine coming on. But different people may have different opinions on that. With regards to other drugs like nonsteroidal anti-inflammatory drugs — and again you take it as soon as possible, as soon as you get these symptoms.”

Triptans are contraindicated in patients with hemiplegic migraine. That’s based on an old hypothesis that the aura, which is the weakness, is due to a lack of blood supply to the brain, and Triptans can cause constriction of blood vessels. There isn’t a lot of research to support whether triptans are indeed safe or not so it’s best to avoid triptans in this group until there is more evidence and data to suggest it’s safe.2

Migraine With Aura Prevention

If people have frequent aura and migraine or migraine with aura, many of the same preventatives that we use for migraine without aura will work with migraine with aura. 

If attacks are so frequent that people are disabled by them, they should be on a preventive medication. People who experience migraine should probably talk to their doctors about what’s right for them, because not everything is going to work for everybody. 

I’ve found that baby aspirin is really good for aura. Sometimes aura without headache, to prevent that, and also to prevent migraine with aura. But you have to know whether your system can tolerate baby aspirin or not. And that should be a conversation between a person and their primary provider. 
I’ve also found calcium channel blockers can be very helpful. Things like Verapamil sometimes are very good for people with migraine with aura.
Dr. Kathleen Digre, past president of the American Headache Society
Tweet

Other preventatives that are helpful preventing migraine with aura include: 

  • antidepressants, such as amitriptyline (Elavil)
  • blood pressure medications, like beta blockers or calcium channel blockers such as candesartan (Atacand), propranolol (Inderal), timolol (Timoptic)
  • anti-seizure drugs, such as topiramate (Topamax), valproate sodium (Depacon)
  • Calcitonin Gene Related Peptide (CGRP) monoclonal antibodies:
    • erenumab (Aimovig)
    • fremanezumab (Ajovy)
    • galcanezumab (Emgality)
    • eptinezumab (Vyepti)
  • Botox
  • neuromodulation devices

There’s some data to suggest that some medications may be helpful for aura. There’s some small studies on a drug called Lamotrigine which suggests that maybe that had some beneficial effect on aura. There’s a drug called Flunarizine which is used quite widely throughout Europe, and there’s again anecdotal evidence from a pediatric study that it was more effective in hemiplegic migraine groups, so maybe a bit more effective in aura.5 

If you’re light-sensitive, sometimes FL-41 or the tinted lenses can be really helpful in preventing migraine attacks, in-between attacks.

Polarized sunglasses are not considered a preventive for those with a light sensitivity unless used outdoors to help reduce glare. People can wear sunglasses outside, because it blocks the light on all wavelengths. The FL-41 and some of these light filters can block certain wavelengths, especially the blue wavelength that seems to be more bothersome to people indoors.

What about other visual phenomena noticed by people living with migraine?

Visual snow

There are some people with migraine who can also get other visual phenomena. For example, there’s an entity called visual snow. Visual snow is very different from an aura. Aura is a discrete neurological event that occurs, typically followed by the headache. Visual snow is a persistent visual phenomenon. It’s like little, tiny dots in the field of vision, like in the old TV sets showing a static snowy pattern. People see visual snow commonly and they can see through it. Their vision can be 20/20, but they continuously see these little visual dots. Some people have blobs of color that they constantly see.

Floaters

Dr. Digre has seen people who feel like they see little things floating around in their vision. People with migraine can have floaters. Lots of people have floaters and people with migraine seem to notice those floaters a little bit more readily. Floaters can be seen easier on a blank wall or in the blue sky. 

Image recurrence

People with migraine also have other strange symptoms such as image recurrence. They can look at an object, and then they can look away and they might see the same object sitting next to them, and that’s called palinopsia. Or they can have their hand go in front of a target and they can almost see their hand trailing across space.

It’s these unusual visual phenomena that people with migraine are more prone to, that are so different from our normal visual world, which makes it challenging for patients to explain to an  ophthalmologist or eye doctor for example.3

Migraine aura later in life

What’s interesting about this aura is as people get older, sometimes they lose the headache but keep the aura, and sometimes that is called later-life migraine accompaniments. It’s still a migraine aura, but it doesn’t trigger the headache.3

 

White Matter Lesions Associated with Migraine with Aura

MRI scans in people with migraine with aura may show T2 hyperintensities which might be concerning for some who ask if they are lesions and what they mean.

These are white-matter lesions, and they do not cause dementia.6

A study done in the Netherlands took several hundred patients, some that have migraine with aura, and they compared them versus a research control group of healthy people. MRIs were conducted on their brains and they measured the dots. Nine years later they found those patients again and then re-measured the dots on the MRI, specifically looking to see if there were cognitive changes that would occur over time. They found that women were more likely to have these dots, but there was no effect on cognition or neurological effects. 

There’s actually data that shows that these white-matter lesions are not a cause for concern. We do not think that they’re causing any damage.6

Patent Foramen Ovale and Migraine

Some people are born with an open passageway between the two top chambers of their heart called the atria. If this passageway is open it’s referred to as a patent foramen ovale (PFO). Learn more about the link between the PFO and migraine in this article.  

Risk of Stroke

Some patients are worried about the risk of stroke as they may have heard that migraine with aura is associated with an increase in risk. Typically the increase in risk is minimal. Learn more about migraine and stroke risk, in this article (coming soon).  

When to see a healthcare provider?

How to talk to them about migraine with aura

Here are a few tips to get the most out of your doctor visit if you suspect you may have migraine with aura:

  • Keep a record of your migraine attacks. How often do they occur? How long do they last?
  • Record what happens during your attacks including sensory disturbances. Do you experience a visual aura? How long does that typically last? Describe the symptoms you may experience such as zigzag lines, flashing lights, or any other classic migraine with aura symptoms. 
  • Tell the doctor what treatments you’ve tried already and ask him/her about both acute and preventive options for your migraine.
  • Another tip is to take a friend or family member with you to your appointment to help you remember questions you wish to ask and also to help you recall the answers provided. There’s a lot that happens in a relatively short period of time and if you’re in pain or tired or experiencing side effects from treatments it is easy to lose track of what is said. 

What to expect from your doctor?

It’s important to recognize that patients with migraine will end up in many different physicians’ offices, especially because one-third have visual symptoms. These symptoms will most likely take them to an ophthalmologist or optometrist.

Sometimes patients with migraine have well-formed visual aura, so it’s very clear what’s going on. But at least half of patients who have migraine without aura will have something wrong with their vision during an attack, such as blurred vision. They can’t quite explain it, they can’t see as clearly, their vision is not as crisp. Things appear blurred or indistinct or something is affecting their vision. Vision impairment is quite common during migraine, so it’s not surprising that they’re going to end up in an eye doctor’s office.

For migraine with or without aura, most people will be treated and managed by the primary care physician. Primary care doctors vary widely in their understanding and interest of migraine. Going to your appointment prepared and informed with questions and requesting a comprehensive treatment plan once a diagnosis is confirmed will help ensure you get the most of our visit.  

Bottom Line

Migraine with aura affects a significant proportion of people with migraine. Its symptoms can feel strange and unsettling and even mimic those of a stroke. But there are effective options to manage migraine and help prevent attacks. 

Tips for migraine with aura are similar to those with general migraine: 

1. Review your lifestyle triggers.

2. Ensure you have a regular sleep pattern.

3. Make sure you are not missing meals.

4. Practice good stress management. 

5. Treat early. There’s evidence that you shouldn’t wait for your migraine attack to build up before you treat it. An established migraine attack is less responsive to treatment than treating at the onset. If you’re going to treat it, treat it at the onset of the attack.

6. Prevention isn’t just for chronic migraine. If you have more than six days of any migraine symptoms per month, consider prevention strategies to stop the migraine attack from occurring in the first place. 

While there is not yet a cure for migraine, it can be effectively managed and controlled. It takes time to learn how migraine affects you and which treatment options and management plans work best for you. Working in partnership with your health care professional is a critical part of your migraine care.