condition

Migraine with aura

The aura associated with migraine is a neurologic warning that a migraine is going to occur. In the common forms this can be the start of a typical migraine or a headache without migraine, or it may even occur in isolation. For a typical aura, the aura needs to be visual, sensory, or dysphasic, lasting longer than 5 min and less than 60 min with the headache starting within 60 min (seeTable 613.3). The importance of the aura lasting longer than 5 min is to differentiate the migraine aura from a seizure with a postictal headache, whereas the 60-min maximal duration is to separate migraine aura from the possibility of a more prolonged neurologic event such as a transient ischemic attack. In a revision to the ICHD-3b criteria, it has been suggested that for a diagnosis of aura there needs to be a positive symptom and not just a loss of function (flashing lights, tingling). The most common type of visual aura in children and adolescents isphotopsia (flashes of light or light bulbs going off everywhere). These photopsias are often multicolored and when gone, the child may report not being able to see where the flash occurred. Less likely in children are the typical adult auras, includingfortification spectra (brilliant white zigzag lines resembling a starred pattern castle) orshimmering scotoma (sometimes described as a shining spot that grows or a sequined curtain closing). In adults, the auras typically involve only half the visual field, whereas in children they may be randomly dispersed. Blurred vision is often confused as an aura but is difficult to separate from photophobia or difficulty concentrating during the pain of the headache. Sensory auras are less common. They typically occur unilaterally. Many children describe this sensation as insects or worms crawling from their hand, up their arm, to their face with a numbness following this sensation. Once the numbness occurs, the child may have difficulty using the arm because they have lost sensory input, and a misdiagnosis of hemiplegic migraine may be made. Dysphasic auras are the least-common type of typical aura and have been described as an inability or difficulty to respond verbally. The patient afterward will describe an ability to understand what is being asked, but cannot answer back. This may be the basis of what in the past has been referred to as confusional migraine, and special attention needs to be paid to asking the child about this possibility and their degree of understanding during the initial phases of the attack. Most of the time, these episodes are described as a motor aphasia, and they are often associated with sensory or motor symptoms. Much less commonly,atypical forms of aura can occur, including hemiplegia (true weakness, not numbness, and may be familial), vertigo or lower cranial nerve symptoms (formerly called basilar-type, formerly thought to be caused by basilar artery dysfunction, now thought to be a more brainstem-based migraine with brainstem aura) (seeTable 613.4), and distortion (Alice in Wonderland syndrome). Whenever these rarer forms of aura are present, further investigation is warranted. Not all motor auras can be classified as hemiplegic migraine spectrum, and they should be differentiated from those very specific migrainous events, because the diagnosis of hemiplegic migraine has genetic, pathophysiologic, and therapeutic implications.

Ref:
Robert M. Kliegman MD, in Nelson Textbook of Pediatrics, 2020

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Added on Aug 29, 2022 by Barbara Van De Keer

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