Migraine aura without headache

Journal of Family Practice, May, 1991 by Donald M. Pedersen, William M. Wilson, George L. White, Jr., Richard T. Murdock, Kathleen B. Digre

Workup

The diagnosis of migraine aura without headache should be made only after the possibility of organic disease has been systematically excluded through a detailed patient history. As Hupp[1] notes, even the astute observer may ascribe a monocular origin to the episodes when the disturbance in the contralateral visual field is not appreciated. Indeed, when visual phenomena occur in the peripheral visual field, an occipital sources is most likely. It is therefore important to instruct the patient that, during an attack, each eye should be occluded in turn so that the field of the uncovered eye can be carefully observed. Hupp suggests displacing one eyeball using a finger. The visual disturbance will move with the eyeball if it originates in the retina, but will remain fixed if it originates in the occipital cortex.[1]

The diagnosis of migraine aura without headache can be entertained if the patient has the major migraine characteristics, including migration of scintillating scotoma, recurrences of similar episodes of 15 to 30 minutes' duration, a history of similar spells with headache, an eventually benign course, and a normal physical, ophthalmologic, and neurologic examination.

Underlying organic disease must always be considered, however, if the history does not fit or if the neuologic examination is abnormal. A computed tomography (CT) scan and magnetic resonance imaging (MRI) are necessary to exclude a mass or lesion, and MRI should be performed if a venous thrombosis is suspected (eg, in a postpartum woman with new-onset migraine equivalents). A hematologic evaluation might include a complete blood and differential count and partial thromboplastin time. A vasculitis panel would include erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibody titer, and serum protein electrophoresis. The cardiovascular evaluation includes electrocardiography, echocardiography, and possibly cardiac angiography. If extracranial carotid narrowing is suspected, noninvasive ultrasound Doppler can be utilized; however, complete carotid evaluation requires cerebral angiography.(1) An electroencephalogram is needed if a seizure is suspected. Treatment

There is a paucity of information on the treatment of migraine aura without headache. No therapy is required for rare occurrence; however, with increased frequency of attacks, some form of intervention seems warranted. Prolonged auras or bothersome auras may respond to rapidly acting effervescent aspirin. This is probably the most useful intervention for the case of migraine aura without headache. Other abortive drugs that might be helpful but are currently without Food and Drug Administration approval for this use are the calcium channel blockers, particularly sublingual nifedipine.

Patients using oral contraceptives who develop migraine symptoms have a higher incidence of neurophthalmic sequelae, including cerebral vascular accidents.(10) Any patient with scintillating scotoma who is using an oral contraceptive should be advised to discontinue the medication and to adopt an alternative form of birth control.