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Migraine with brainstem aura (basilar-type migraine)

Carrie Elizabeth Robertson, MD
Section Editor
Jerry W Swanson, MD, MHPE
Deputy Editor
John F Dashe, MD, PhD


Migraine with brainstem aura (MBA), previously called basilar-type migraine, is a rare form of migraine with aura wherein the primary signs and symptoms seem to originate from the brainstem, without evidence of weakness. Originally described by Bickerstaff in 1961 as a distinct clinical entity [1], previous descriptions consistent with MBA were given by Aretaeus in ancient Greece and by Gowers in 1907 [1-3].

The terminology used to describe what some have called "Bickerstaff syndrome" has evolved over time; "basilar artery migraine" was replaced by "basilar migraine" and then by "basilar-type migraine." The disorder is now called migraine with brainstem aura [4]. Each subsequent term attempted to maintain the identity of the disorder, while weakening the association with the basilar artery. This evolution has occurred because there is no evidence that the basilar artery is involved, and because some of the symptoms may localize outside the territory of the basilar artery.

This topic will review the clinical manifestations, diagnosis, and treatment of MBA. Other aspects of migraine are discussed separately. (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults".)


Most experts now consider MBA as a subset of migraine with aura, and its etiology rests in the theory that cortical spreading depression produces the aura. Cortical spreading depression is a self propagating wave of neuronal and glial depolarization that spreads across the cerebral cortex (see "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults", section on 'Cortical spreading depression'). The difference between MBA and migraine with typical aura is that the location of the aura symptoms in MBA primarily involves the brainstem or the bilateral occipital hemispheres, whereas in typical migraine the aura symptoms are mainly restricted to a unilateral hemisphere. However, cortical spreading depression as the cause of altered local blood flow and metabolism in the brainstem has only been proven in animals [5].

Bickerstaff invoked the vascular hypothesis, the prevailing theory at the time, to explain the symptoms of "basilar artery migraine" that were referable to either the brainstem or the bioccipital hemispheres [1]. In a later publication, he acknowledged that he had "rather loosely termed" this condition basilar artery migraine [6]. In truth, there is no evidence that the basilar artery is involved in the etiology of MBA, and abnormal flow in the basilar artery has never been proven in MBA. Only two cases, one with familial hemiplegic migraine with MBA-like symptoms, and one with MBA, have shown ictal spasm of the basilar artery on angiography [7,8]. Another case was reported with reduced mean flow velocity in both posterior cerebral arteries during a single MBA episode with resolution after the aura [9]. Despite these reports, it is unlikely that reversible ischemia is the source of the prolonged symptoms that occur with MBA.


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Literature review current through: Sep 2016. | This topic last updated: Feb 10, 2015.
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