Migraine with Brainstem Aura (Basilar Type Migraine)

The Basics

Migraine with brainstem aura has been previously referred to as basilar artery migraine, basilar migraine and basilar-type migraine. The use of basilar artery, basilar-type or basilar is misleading as it implies that the basilar artery is the origin of the attack. It was termed basilar by Bickerstaff in 1961. He reported his beliefs that the events of migraine with brainstem aura were the result of short-term narrowing or spasm of the basilar artery. This belief remained a concern for over three decades. It even resulted in the exclusion of people with migraine with brainstem aura from clinical trials of triptans for migraine. The absence of these people in trials led the Federal Drug Administration (FDA) to contraindicate use of triptans in people with migraine with brainstem aura.

Migraine is now known as a common but complex genetic disorder involving environmental factors. The nerves rather than the vessels are the cause of aura in migraine with brainstem aura as they are in other migraine types. Bickerstaff suggested that migraine with brainstem aura was more common in adolescent females, however migraine with brainstem aura is now known to affect all age groups. Migraine with brainstem aura does exhibit the same female predominance seen overall in migraine.

Symptoms of Migraine with brainstem aura

Migraine with brainstem aura is a migraine-type that has aura symptoms originating from the base of the brain (brainstem) or both sides of the brain (cerebral hemispheres) at the same time.

People who experience migraine with brainstem aura also experience migraine with typical aura symptoms, including:

  • Visual (Examples include sparkles or zigzag lights in the vision that may move or get larger. Generally on only one side of your vision).
  • Sensory (Examples include numbness or tingling that travels up one arm to one side of the face).
  • Speech/language symptoms (Examples include trouble producing words even though you know what you want to say or trouble understanding what people are saying).

Each symptom is fully reversible and usually only lasts up to 60 minutes each. There should not be any motor (weakness or paralysis) or retinal (vision changes or loss in one eye only) symptoms.

In addition, people with migraine with brainstem aura get brainstem aura symptoms such as:

  • Dysarthria (slurred speech)
  • Vertigo (feeling of movement/spinning of self or environment)
  • Tinnitus (ringing in ears)
  • Hypacusis (impaired hearing)
  • Diplopia (double vision)
  • Ataxia (Unsteady/Uncoordinated movements)
  • Decreased level of consciousness

Many of these symptoms may occur with anxiety and hyperventilation, and therefore are subject to misinterpretation.

Please refer to the International Classification of Headache Disorders 3rd edition (beta version) website for more information on the criteria used to diagnosis migraine with brainstem aura: https://www.ichd-3.org/1-migraine/1-2-migraine-with-aura/1-2-2-migraine-with-brainstem-aura/

Diagnosis of Migraine with brainstem aura

People suspected of having migraine with brainstem aura should be carefully assessed by their doctor for an underlying cause, including getting imaging of the brain and vessels in the head. An EEG is often performed to rule out seizure disorders; especially, when people experience confusion or change in the alert state.

Doctors should also make sure that the patient does not have a different primary headache disorder that can mimic migraine with brainstem aura. Examples of other primary headache disorders that mimic migraine with brainstem aura include hemiplegic migraine and migraine with typical aura.

It is essential that the diagnosis be definitive and correct.

Treatment

Migraine-specific medications such as the triptans and ergotamines are contraindicated for migraine with brainstem aura. This is because they were not studied in scientific trials of migraine due to a belief that artery narrowing or spasm was the cause of these symptoms. The triptans and ergotamines are known to constrict blood vessels, and were believed to possibly cause safety issues if used.

Such beliefs, however, did not lead to the exclusion of migraine with typical aura patients. As described above, migraine with brainstem aura is essentially a migraine with aura subtype. Reports of use of triptans in patients with basilar migraine, familial hemiplegic migraine, or migraine with prominent or prolonged aura have emerged, where no harm was done (no adverse events) with excellent relief of headache and symptoms. However, as these are limited reports, generally triptans or ergotamines should be avoided in these patient groups.

For acute treatment often a combination of nonsteroidal anti-inflammatory (NSAID) medications with an anti-nauseant, like phenothiazine, are used and can be effective.

Of the preventive medications, topiramate, verapamil and lamotrigine are most commonly used. Otherwise, migraine with brainstem aura is generally managed with traditional preventatives although many recommend that beta-blockers be avoided due to rare reports of complicating events.

Disability and Prognosis

As with other forms of migraine, migraine with brainstem aura can be disabling. Migraine with brainstem aura is often more debilitating than migraine with typical aura due to aura intensity, number of symptoms and longer length.

For many, aura in migraine with brainstem aura commonly becomes more typical during later mid-life. While disabling, symptoms of migraine with brainstem aura are usually more frightening than harmful. A concern or myth about stroke risk has existed for decades. There is no evidence that migraine with brainstem aura patients have any greater stroke (cerebrovascular) risk than migraine with typical aura. Migraine with aura does have a slightly higher stroke risk than migraine without aura, so optimal prevention and knowledge of stroke risk factors and their control is important.

Summary

Migraine with brainstem aura is one type of migraine with aura, and it can be a frightening head pain disorder. As with other forms of migraine, it is necessary to have an accurate diagnosis and effective treatment plan. This requires use of that treatment as early as possible when pain is mild, without waiting to learn how extreme the pain will become. Once diagnosed with migraine with brainstem aura, it is important to minimize the frequency of attacks through optimal prevention. Also, contact your provider if your symptoms or migraine pattern change. Without consulting a knowledgeable provider, it’s impossible to be sure that new symptoms or changes in pattern are attributable to migraine with brainstem aura, and that no other condition is present.

Resources:

The International Headache Society. https://www.ichd-3.org/1-migraine/1-2-migraine-with-aura/1-2-2-migraine-with-brainstem-aura/
Kirchmann M, Thomsen L, Olesen J. Basilar-type migraine: Clinical, epidemiologic, and genetic features. Neurology 2006;66: 880-886.
Klapper J, Mathew N, Nett R. Triptans in the treatment of basilar migraine and migraine with prolonged aura. Headache. 2001;41:981-984.