Silent Migraine: A Guide

By Dr. Jennifer Robblee

Headache can be a common migraine symptom. But not all forms of migraine come with headache. “Typical aura without headache”—previously known as “acephalgic migraine” and sometimes called “silent” migraine—is when someone has a migraine aura without any head pain.  

Typical aura without headache, despite a lack of head pain, can still be disabling for those who live with it. It also has its own set of considerations during diagnosis and treatment. The following is a breakdown of the basics on this “silent” form of migraine. 

Definition

“Acephalgic migraine” is an older term. The modern classification—“typical aura without headache”—is exactly what it sounds like: a migraine aura that lacks the accompanying headache. 

The definition of an aura is a recurrent attack that features temporary visual, sensory and/or speech/language symptoms. These symptoms usually develop gradually and generally come before headache. This, however, is not in the case with typical 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 5 and 60 minutes.

Treatment for Silent Migraine

Treating typical aura without headache can be difficult. Since many medications (oral triptans and NSAIDs) actually 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 “silent” migraine. Some medications have been tried, but there aren’t any good, large studies to guide them. There is nothing with an 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 very 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 very low. For example, there are about 800,000 strokes annually. Half of these strokes occur among women, and 2,000 to 3,000 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 those 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—especially at higher doses—are associated with an even higher stroke risk in aura patients.

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 present similarly. One of the biggest differences, however, is that stroke has a sudden onset while aura slowly ramps up. 

The Effect on Patients

Research is a bit limited, but we know that migraine presents patients with a high burden from different symptoms. For a patient who’s having visual aura that comes on in situations like driving, it can be very disconcerting. It definitely affects day-to-day functioning, even if headache and other features aren’t there. This is especially true if it’s the first time is happens or there’s a change in how it presents. Typical aura without headache—the “silent” migraine—can be quite scary.

 —Jennifer Robblee, MD, is part of the Mayo Clinic in Scottsdale, Arizona