Updated: September 23, 2021
Migraine aura without headache, sometimes referred to as “silent migraine,” does not feature any head pain.
By Dr. Jennifer Robblee
Headache can be a common migraine symptom. But not all forms of migraine come with headache. “Migraine aura without headache”—previously known as “acephalgic migraine” and sometimes called “silent migraine”—is when someone has a migraine aura without any head pain.
Despite a lack of head pain, migraine aura without headache is still disabling for those who live with it. It also has its own set of considerations for diagnosis and treatment. The following is a breakdown of the basics of this form of migraine.
“Acephalgic migraine” is an older term. The modern classification—“migraine aura without headache”—is exactly what it sounds like: a migraine aura that lacks the accompanying headache.
This condition has also been called “silent migraine,” but that is no longer the preferred way of referring to it. While the term “silent migraine” was historically used to describe this condition, the use of the word “silent” may send the wrong message and diminish what the person is experiencing.
Aura—even when experienced without head pain—is an extremely debilitating phase of migraine. The most appropriate and accurate term is “migraine aura without headache.” Diagnostic criteria consider it a migraine attack that skips the headache phase.
The definition of an aura is a recurrent attack that features temporary visual, sensory or speech and language symptoms. These symptoms usually develop gradually and generally come before headache. This, however, is not the case with migraine aura without headache.
Symptoms also usually happen before migraine symptoms, like nausea and sensitivity to light and sound, appear. An aura is an episodic and transient event that evolves over several minutes and generally lasts between five and 60 minutes.
Treatment for Aura Without Headache
Treating migraine aura without headache can be difficult. Since many medications (oral triptans and NSAIDs) take longer to work than aura’s duration, some people don’t take any as-needed medication. Others, however, may find that associated symptoms like nausea and sensitivity to light and sound will improve if treated.
There are not a lot of tested medications for this type of migraine. Some medications have been tried, but there aren’t any good, large studies to guide them. There is nothing with FDA approval in this indication, and the condition is managed on a case-by-case basis.. Some smaller studies and case reports suggest the use of magnesium, aspirin and lamotrigine. For people with prolonged aura, there have been some treatment attempts with intranasal ketamine. These, however, are small studies, and this is very much an off-label use.
Comorbidities and Confused Conditions
You may or may not be aware that having migraine with aura (with or without headache) increases the risk of stroke. However, it is important to keep in mind that the overall risk is still low. For example, there are about 800,000 strokes annually. Half of these strokes occur among women, and 2,000 to 3,000 of these might be related to migraine, according to Dr. Gretchen Tietjen, the chair of the University of Toledo’s Department of Neurology. The risk seems to involve patients who experience aura and not necessarily those without aura. This is true whether you have the associated headache or not. Additionally, estrogen-containing hormone treatments are associated with even higher stroke risk in aura patients, especially when taken at higher doses.
Doctors may want to rule out rare presentations of other conditions, like a seizure or other visual patterns associated with migraine. This includes “visual snow”—where people see white or black dots in their visual fields—or other visual symptoms that might not be related to migraine. On a similar note, aura is commonly confused with stroke because they may present similarly. However, one of the most significant differences is that stroke has a sudden onset, whereas aura slowly ramps up.
The Effect on Patients
Research is limited, but we know that migraine presents patients with a huge burden from different symptoms. For a patient who has visual aura that comes on in situations like driving, it can be very disconcerting. It affects day-to-day functioning, even if headache and other features aren’t there. This is especially true if it’s the first time it happens, or there’s a change in how it presents. Migraine aura without headache can be quite scary.
—Jennifer Robblee, MD, is part of the Mayo Clinic in Scottsdale, Arizona