What is Migraine with Brainstem Aura?

Migraine with brainstem aura was earlier referred to as basilar migraine or basilar-type migraine. However, the International Headache Society now classifies this type of migraine as migraine with brainstem aura.⁽¹⁾ This type of migraine is considered to be a subtype of migraine with aura, typically characterized by pain in the back of the head on both sides. This type of migraine tends to start in the brainstem and is accompanied by an aura. An aura is a term used to refer to a set of symptoms like speaking and hearing difficulty, vertigo, and loss of muscle control that set in some time before the migraine attack.^{(2, 3, 4, 5, 6)}

Migraine with brainstem aura can be excruciatingly painful as well as frightening as many of the symptoms of this type of migraine, including loss of balance and slurred speech, are similar to the signs and symptoms of a stroke. In some very rare cases, a migraine with brainstem aura is linked with a coma or seizures.^{(7, 8)}

This type of migraine and its descriptions have been found to go back all the way to ancient Greece. However, it was only in 1961 that a British neurologist by the name Edwin R. Bickerstaff actually identified and diagnosed the condition and also suggested that it was caused by some type of issue with the basilar artery. The basilar artery is responsible for supplying the brainstem with blood. While this theory has since then been debunked, but medical experts and scientists are still not clear about what are the exact causes of migraine with brainstem aura. There are many things that are still a mystery about this condition, and because it is so rare, even its existence gets questioned by many from time to time.⁽²⁾

As mentioned above, migraine with brainstem aura is classified as a subtype of migraine with aura. This means that this type of migraine can be accompanied by symptoms that affect your senses, especially your sight. Aura refers to the set of symptoms that precede a migraine episode.

In migraine with brainstem aura, you may experience symptoms of a visual aura, which include seeing spots or lines in your vision. You can also see abnormal flashes of lights in your field of vision. During these visual disturbances or soon afterward, you are likely to experience a migraine headache, but this may not always be the case.^{(9, 10, 11)}

The good part is that migraine with brainstem aura is very rare. Recent studies indicate that this type of a migraine affects just 0.04 percent of the population, 1.6 percent of people with headaches, and 10 percent of people who have migraine with visual aura.^{(2, 12, 13)}

Migraine with brainstem aura tends to last for only an hour or so, while severe migraines with brainstem aura may even last for a couple of hours, but these are not usually caused by any serious condition. With the proper treatment and developing an understanding of the various causes, migraine with brainstem aura can be adequately managed without a disruption to your everyday life. While the best treatments still remain a bit elusive, but as scientists understand more about this condition, healthcare providers will be able to help patients with this condition in a better manner.

According to the third edition of the International Classification of Headache Disorders (ICHD-3), which is published by the International Headache Society (IHS), a migraine with brainstem aura is technically defined as “a migraine with aura symptoms that originates from the brainstem, but has no motor weakness.”⁽¹⁴⁾

So in order for a person to be diagnosed with this condition, they need to meet the criteria for migraine with aura. In any case, with this type of migraine, you are likely to experience many of the common signs and symptoms of a classic migraine with aura. These include:^{(15, 16)}

• Seeing spots, lines, or stars in your field of vision.
• Seeing flashing lights in your vision (with an absence of an external source of light)
• Feeling numb in the face, head, or hands
• Feeling abnormally tired, weak, or exhausted
• Losing full vision
• Seeing ‘static’

Since this type of migraine begins in the brainstem, you may experience the symptoms on one side or on both sides of the body. Symptoms that are specific to migraine with brainstem aura include:

• Experiencing double vision (meaning not being able to focus your eyes or seeing two of everything)
• Feeling nauseous
• Feeling like your surroundings are spinning – this may happen to a point where you are not able to stand up straight. This symptom is known as vertigo.
• Feeling disoriented or confused.
• Not being able to pronounce words properly or speak, or having slurred speech.
• Having an excruciatingly painful headache.
• Changes in the ability to hear – this may include hearing ringing in your ears, a condition known as tinnitus.
• Not being able to control your muscles, known as ataxia
• Losing complete or partial consciousness.

In order to be diagnosed with migraine with brainstem aura, you must experience at least two of the above-mentioned symptoms. It is important to note, though, that paralysis or weakness on one side of the body, along with any of these symptoms, might give you a diagnosis of hemiplegic migraine instead of a migraine with brainstem aura.^{(17, 18, 19)} Vision loss or any other changes that only affect one eye is likely to lead to a diagnosis of retinal migraine.^{(20, 21)}

Vertigo is one of the major symptoms of the aura that precedes a migraine episode with brainstem aura. Vertigo is a term used to refer to a sense of movement when no such movement is happening. It is usually described as spinning, pitching forward, or a sensation of rocking.

Vertigo associated with migraine with brainstem aura tends to only last for a short time, from a few minutes to up to an hour. It is possible to have this aura symptom with or without the headache following it.

When vertigo is the main symptom of the oncoming migraine attack, it is usually called as a vestibular migraine. A vestibular migraine usually does not involve any head pain, but it can be very disorienting. Symptoms of a vestibular migraine tend to subside either within a few minutes, or it can last up to a couple of days.^{(22, 23, 24)}

The causes of migraine with brainstem aura are not clearly known. While some research indicates the cause to be abnormal nerve activity, other studies show that a change in blood flow to the brainstem is responsible for these kinds of migraine.^{(25, 5)}

Researchers are also looking at the possible genetic causes behind this type of migraine, though it is not usually believed that migraine with brainstem aura is an inherited condition.⁽²⁶⁾ It is believed that migraine with brainstem aura might be caused by an alteration or mutation in the CACNA1A gene or ATP1A2 gene.

Even though the exact causes of migraine with brainstem aura are not clearly understood, researchers do agree that lifestyle and environmental triggers do play a role in the onset of this type of migraine episode.

According to a study published in the Pain Medicine journal, emotional situations and sleep disorders are the most common triggers of migraine with brainstem aura, with emotional situations accounting for 74 percent of the cases and sleep disorders accounting for 65 percent.⁽²⁷⁾

Some of the other common triggers of migraine with brainstem aura include:

• Long exposure to sunshine
• Changes in altitude or weather
• Stress
• Alcohol
• Motion sickness
• Fatigue
• Lack of sleep
• Strong smells
• Bright or flashing lights
• Strong smells
• Certain foods and beverages, including those containing alcohol and caffeine
• Certain medications like birth control pills or blood pressure medicatio0ns
• Experiencing an epilepsy seizure

Migraine with brainstem aura episodes tends to occur most frequently in teenagers and young adults. According to data by the Genetic and Rare Disease Information Center, this type of migraine is most commonly observed in adolescent women.⁽⁵⁾

Additionally, living in environments with sensory triggers can increase your risk. If recurrent weather changes, stress, bright lights, or certain smells trigger your migraine episodes, you may think about moving to a different environment that has fewer of these triggers to reduce the frequency of your migraine attacks.

Most people associate migraine with an excruciating headache. However, it is possible to have migraine without the head pain. When you experience the aura symptoms, but these are not followed by a headache, it is known as silent migraine.^{(28, 29, 30)} In such cases, while the aura symptoms are not typically a cause of concern, but they can still disrupt your day-to-day life.

Silent migraine attacks, though, can be unsettling, especially if your aura symptoms are severe. This is why it is always a good idea to have a check-up with a doctor to make sure that a more serious underlying medical condition is not causing these aura symptoms.

The symptoms of a migraine with brainstem aura and a stroke can be pretty similar, due to which many people worry that they are having a stroke when, in fact, they have a migraine attack. Research shows that two percent of people initially diagnosed as having a stroke during treatment at an emergency room were eventually diagnosed with migraine with brainstem aura.⁽³¹⁾

On the other hand, since a stroke generally causes intense head pain, many people believe they are having a migraine attack when they are actually having a stroke and need immediate medical assistance. This is why medical experts recommend that you seek emergency care as soon as possible, regardless of whether you are in doubt about if you are having a stroke or a migraine.

It is important to know that symptoms like visual disturbances, speech difficulties, and numbness can be a part of both a stroke and migraine with brainstem aura.

A migraine with brainstem aura is most likely to mimic a type of stroke known as a transient ischemic attack (TIA). A transient ischemic attack is usually referred to as a mini stroke, and it lasts for less than 24 hours and does not cause any permanent damage to the brain.⁽³²⁾

It is common for some people to worry that their severe migraine attack will turn into a stroke. While both the condition are known to happen at the same time in some rare cases, but there is no evidence to show that one causes the other. There is also very little proof that shows that strokes are more likely to happen during a migraine attack than at any other time.⁽³³⁾

For a diagnosis of migraine with brainstem aura to be made, two migraine episodes have to include at least two of the main brainstem aura symptoms. Most migraine episodes of this type involve many other aura symptoms as well, but these are the distinguishing symptoms that doctors look for:

• Vertigo
• Tinnitus
• Impaired ability to produce speech
• Double vision
• Hearing disruption
• Inability to control body movements
• Reduced level of consciousness

There are no medical tests available that can confirm a diagnosis, due to which tests are usually prescribed to rule out other conditions, such as a stroke or a seizure. Diagnosing migraine with brainstem aura is challenging as migraine attacks usually mimic many other conditions and also have symptoms that are similar to other conditions. Due to this, migraine attacks are sometimes investigated as other conditions, and other conditions may be investigated as being migraine.

This is why it is essential to provide a complete health history and a clear description of your symptoms.

Since there is not always a traceable cause for migraine, it is difficult to treat the underlying causes. Treating the symptoms of migraine with brainstem aura is the best way of getting relief from the pain and discomfort.

There are some commonly prescribed medications that help reduce the symptoms of migraine with brainstem aura. These include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) for alleviating the head pain
• Small molecule CGRP antagonists like ubrogepant (brand name: Ubrelvy) and rimegepant (brand name: Nurtec)
• Anti-nausea medications like metoclopramide (brand name Reglan)

Changes in your lifestyle can also help treat migraine and reduce the frequency of your attacks. These changes may include:

• Get regular sleep for at least six to eight hours per night.
• When you first notice the symptoms of migraine, stop what you are doing and try to stay in a dark room. Putting an ice pack on the back of your neck may help prevent the onset of the more severe symptoms.
• Take a break and relax whenever you feel the migraine or aura symptoms coming on.
• Identify what foods and beverages trigger your migraine and restrict the intake of these trigger foods and drinks. Cutting them out altogether is a good idea.

Migraine with brainstem aura can usually be treated at home with ice packs, over-the-counter medications, rest, and dietary and lifestyle changes. However, if you find that the symptoms restrict your ability to do your everyday tasks, or if the migraine attacks cause you to lose consciousness, it is essential to consult a doctor or go to your nearest emergency room for treatment.

You will be able to find out if your symptoms are being caused by migraine with brainstem aura or a more serious underlying condition. If you are diagnosed with migraine with brainstem aura, you can get help dealing with the disturbing symptoms. Migraine with brainstem aura can be a disruptive condition, but it is very much treatable.

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