Dr. Jennifer Robblee of The Mayo Clinic, walks us through the more-common form of migraine
Just like the people it affects, not every migraine is the same. One of the most common differences between different types of migraine is how it presents. Some people experience an “aura,” which are transient sensory changes typically occurring before pain starts (most commonly an obstructive visual symptom lasting 5-60 minutes). More commonly, however, migraine presents without aura—about 70-75% of migraine patients do not experience aura.
Once known as “common migraine,” migraine without aura is what patients are more likely to experience. Knowing what migraine without aura is and how it differs from migraine with aura is important for patients to understand when learning about their condition and how best to treat it.
According to Dr. Jennifer Robblee, of The Mayo Clinic, migraine without aura is a clinical diagnosis. While there is no surefire test for detecting the presence of migraine, Robblee says there are a number of symptoms and factors that doctors can point to so they can make a diagnosis.
The diagnosis is reached by reviewing the patient’s personal and family medical history, studying symptoms and conducting an examination. Robblee notes that doctors do not diagnose migraine—or any other type of headache—based on imaging.
“Less than 1% of all brain imaging has a sinister finding in headache, so generally your imaging is going to look normal,” she says. “If we see anything, it’s probably not related to migraine (but still could be serious). So there are certain things we need to know and look for to reach an accurate diagnosis.”
If there are any atypical features or red flags in a patient’s history or examination, further testing may be warranted.
The Phases of Migraine Without Aura
A migraine attack in patients without aura does not stop and start with the headache itself, Robblee says.
“Migraine causes disability not just during the pain, but also during a period of time before and after,” she notes
This can consist of a combination of three phases: premonitory, headache and postdrome.
The premonitory phase may be experienced hours or even days before a migraine attack.
“This is like a warning before the headache starts,” says Robblee “This can happen in migraine without aura and migraine with aura.”
Potential symptoms of the premonitory phase include:
- Food cravings
- Constipation or diarrhea
- Mood changes (depression, irritability, etc.)
- Muscle stiffness, especially in the neck
- Increased frequency of urination
- Sensitivity to light
- Sensitivity to sound
The pain of migraine without aura can range in intensity but typically is moderate to severe. It can be so intense that it is difficult to comprehend by those who have not experienced it. Characteristics of the headache phase may include:
- Headache pain lasting 4-72 hours when untreated
- Pain on one side of the head
- Moderate to severe intensity
- Throbbing pain
- Worsening of headache with physical activity
- Nausea and/or vomiting
- Sensitivity to light and sound
Even after the headache is over, the migraine attack may continue during what’s known as the postdrome phase. The majority of patients with migraine take hours to fully recover; some take days. Many people describe postdrome as feeling “like a zombie” or “hungover.” These feelings are often attributed to medications taken to treat the migraine, but may well be caused by the migraine itself.
The symptoms of postdrome may include:
- Lowered mood levels, especially depression
- Poor feelings of well-being
- Poor concentration and comprehension
Treatment of migraine with and without aura is largely similar, Robblee says. There are a number of options for treatment that should be explored with the help of a doctor.
Treatment plans for migraine without aura include:
- Acute medications for use at onset of a headache attack to try to break it
- Preventive medication to help reduce the frequency and severity of headache attacks
- Non-medication preventive treatments such as biofeedback and cognitive behavioral therapy
- Addressing risk factors such as depression, anxiety, snoring, obesity, etc.
Robblee highlights, however, that one thing that should not be included as a rescue medication is opioids. She also notes that medications that contain butalbital can significantly contribute to medication-overuse headache.
“It’s much higher-risk,” she says. “So those are not recommended in headache as a frequent rescue treatment.”
Living with Migraine
While migraine with and without aura are both very real conditions, there are certain difficulties that patients with migraine without aura face due to the lack of visible symptoms, Robblee says
“People with migraine with aura often say that they can’t see, for example, and people might understand that a bit more,” she says. “I think a lot of people don’t understand how debilitating migraine can actually be.” Those living with migraine are encouraged to discuss their symptoms with loved ones and sympathetic coworkers, as migraine can affect both work and family life.