· Migraine without aura, or common migraine, is the most common type of migraine and constitutes about 80% of migraine type headaches.
· Migraine with aura, or classic migraine, is seen less frequently.
· Patients typically develop headache symptoms after the aura has resolved.
· The only difference between these two types of headaches is the presence of a preceding aura.
o These auras are typically focal neurologic symptoms and are most commonly visual.
o They last for 10 to 20 minutes (rarely up to 1 hour) and then fully resolve.
o They are commonly characterized as a bright rim of light around an area where vision has been lost (scintillating scotomas); a “zigzagged” wall that moves slowly across the field of vision (fortification spectrums); a flash of light or brief spark (photopsias); or simply blurred vision.
Signs and Symptoms
· Migraine headaches are often described as unilateral, pulsating, and of moderate to severe intensity.
· Patients often have associated symptoms that can include nausea, vomiting, photophobia (light), phonophobia (sound), osmophobia (odor) or lightheadedness.
· Cognitive impairment, although rare, can occur. Despite this known occurrence, patients with cognitive impairment should still be evaluated for other more concerning etiologies of altered mental status and headache.
o Basilar type migraines begin with an aura affecting neurologic functions of the brainstem.
o These patients may have visual disturbance, at times as severe as blindness, dysarthria, vertigo, tinnitus, paresis and altered levels of consciousness.
o Like other auras, these symptoms should completely resolve within an hour.
o Hemiplegic migraines begin with an aura that causes a hemiplegia, often associated with sensory changes.
o The motor findings march slowly while affecting additional muscle groups, unlike a stroke, in which the motor function is affected at the same time.
o These symptoms resolve within the hour and are followed by a classic headache.
o Ophthalmoplegic migraines are a rare type of migraine which involves unilateral headache and ocular nerve findings.
o The most commonly affected cranial nerve is the third nerve and can lead to both motor deficits and pupillary findings.
o As in other cases where focal neurologic findings are noted, patients should be evaluated for acute intracranial pathology.
Linda Regan, MD FACEP
Program Director, Emergency Medicine Residency
Johns Hopkins Medical Institutions