What is a migraine with brainstem aura?

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What is a migraine with brainstem aura?

A migraine with brainstem aura (MBA), previously known as basilar-type migraine or basilar migraine, is a subtype of migraine that involves symptoms originating from the brainstem or both hemispheres of the brain but does not include motor weakness. This type of migraine is characterized by specific neurological symptoms that precede the headache phase and are linked to the brainstem’s function.

Characteristics of Migraine with Brainstem Aura

Aura Symptoms
- Brainstem-Related Symptoms: The aura phase in MBA includes symptoms that are typically associated with the brainstem, such as:
  - Dysarthria: Slurred or difficulty speaking.
  - Vertigo: A sensation of spinning or dizziness.
  - Tinnitus: Ringing or buzzing in the ears.
  - Diplopia: Double vision.
  - Ataxia: Uncoordinated movements or difficulty with balance.
  - Decreased Level of Consciousness: Confusion, feeling faint, or even passing out (though this is rare).
  - Visual Symptoms: Involvement of both visual fields in both eyes, such as visual disturbances or temporary loss of vision.
Migraine Headache Phase
- Location: The headache is typically located at the back of the head (occipital region) but can spread to other areas.
- Quality: It is usually throbbing or pulsating in nature.
- Severity: The pain can range from moderate to severe and is often accompanied by nausea, vomiting, and sensitivity to light (photophobia) and sound (phonophobia).
- Duration: The headache phase typically lasts 4 to 72 hours.
No Motor Weakness
- Unlike hemiplegic migraine, which involves motor weakness, migraine with brainstem aura does not include motor symptoms. If motor weakness is present, a different diagnosis, such as hemiplegic migraine, should be considered.

Diagnosis

Clinical Evaluation: Diagnosis is primarily based on the patient’s history and symptom description. A typical migraine with brainstem aura must meet specific criteria outlined by the International Classification of Headache Disorders (ICHD).
Exclusion of Other Conditions: It is essential to rule out other neurological conditions that could cause similar symptoms, such as transient ischemic attacks (TIAs) or stroke. Neuroimaging (like MRI) may be used to exclude other causes.
Aura Duration: The aura typically lasts 5 to 60 minutes and usually precedes the headache phase. However, some symptoms may persist into the headache phase.

Triggers

Common triggers for MBA are similar to those for other types of migraines and may include:

Stress
Hormonal changes (e.g., menstruation)
Certain foods (like chocolate, cheese, or red wine)
Sleep disturbances
Dehydration
Environmental factors (such as bright lights or loud noises)

Treatment and Management

Acute Treatment
- Medications: Treatment of an acute migraine with brainstem aura may involve the use of NSAIDs (e.g., ibuprofen), acetaminophen, or triptans. However, the use of triptans in MBA is controversial and should be done under medical supervision due to concerns about vasoconstriction and potential risk of stroke, although evidence is mixed.
- Rest: Lying down in a dark, quiet room can help alleviate symptoms during an attack.
Preventive Treatment
- Medications: If migraines with brainstem aura are frequent or severe, preventive medications may be prescribed, such as beta-blockers, calcium channel blockers, or antiepileptic drugs.
- Lifestyle Modifications: Identifying and avoiding triggers, maintaining regular sleep patterns, staying hydrated, and managing stress are important preventive strategies.
Monitoring and Follow-Up
- Regular Check-Ups: Due to the complexity of this migraine subtype, regular follow-up with a healthcare provider is important to monitor the condition and adjust treatment as necessary.
- Migraine Diary: Keeping a diary of migraine attacks, including aura symptoms, duration, triggers, and response to treatment, can help in managing the condition more effectively.

Prognosis

Long-Term Outlook: Many people with migraine with brainstem aura experience an improvement in symptoms over time, particularly with effective management and avoidance of triggers. However, due to the potential severity of symptoms, careful monitoring and treatment are essential.
Stroke Risk: Although migraines with aura, in general, have been associated with a slight increase in stroke risk, this risk remains low. It is important for individuals with MBA to manage cardiovascular risk factors, such as high blood pressure, smoking, and obesity.

Conclusion

Migraine with brainstem aura is a rare but distinct subtype of migraine characterized by symptoms linked to the brainstem, such as vertigo, dysarthria, and ataxia, without motor weakness. Proper diagnosis and management are crucial to prevent complications and improve quality of life. Treatment typically involves a combination of acute medications, preventive therapies, and lifestyle modifications tailored to the individual.