Migraine with brainstem aura (basilar-type migraine)
- Carrie Elizabeth Robertson, MD
Carrie Elizabeth Robertson, MD
- Assistant Professor of Neurology
- Mayo Clinic College of Medicine
INTRODUCTION AND DEFINITION
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 , 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 . 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 .
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 . In a later publication, he acknowledged that he had "rather loosely termed" this condition basilar artery migraine . 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 . Despite these reports, it is unlikely that reversible ischemia is the source of the prolonged symptoms that occur with MBA.
- Bickerstaff ER. Basilar artery migraine. Lancet 1961; 1:15.
- Pearce JM. Historical aspects of migraine. J Neurol Neurosurg Psychiatry 1986; 49:1097.
- Gowers WR. The Borderland of Epilepsy: Faints, vagal attacks, vertigo, sleep, symptoms, and their treatment, Churchill, London 1907.
- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629.
- Mraovitch S, Calando Y, Goadsby PJ, Seylaz J. Subcortical cerebral blood flow and metabolic changes elicited by cortical spreading depression in rat. Cephalalgia 1992; 12:137.
- BICKERSTAFF ER. The basilar artery and the migraine-epilepsy syndrome. Proc R Soc Med 1962; 55:167.
- Jensen TS, de Fine Olivarius B, Kraft M, Hansen HJ. Familial hemiplegic migraine--a reappraisal and a long-term follow-up study. Cephalalgia 1981; 1:33.
- Laurent B, Michel D, Antoine JC, Montagnon D. [Basilar migraine with alexia but not agraphia: arterial spasm on arteriography and the effect of naloxone]. Rev Neurol (Paris) 1984; 140:663.
- La Spina I, Vignati A, Porazzi D. Basilar artery migraine: transcranial Doppler EEG and SPECT from the aura phase to the end. Headache 1997; 37:43.
- Ambrosini A, D'Onofrio M, Grieco GS, et al. Familial basilar migraine associated with a new mutation in the ATP1A2 gene. Neurology 2005; 65:1826.
- Robbins MS, Lipton RB, Laureta EC, Grosberg BM. CACNA1A nonsense mutation is associated with basilar-type migraine and episodic ataxia type 2. Headache 2009; 49:1042.
- Kirchmann M, Thomsen LL, Olesen J. Basilar-type migraine: clinical, epidemiologic, and genetic features. Neurology 2006; 66:880.
- Thomsen LL, Eriksen MK, Roemer SF, et al. A population-based study of familial hemiplegic migraine suggests revised diagnostic criteria. Brain 2002; 125:1379.
- Haan J, Terwindt GM, Ophoff RA, et al. Is familial hemiplegic migraine a hereditary form of basilar migraine? Cephalalgia 1995; 15:477.
- Lapkin ML, Golden GS. Basilar artery migraine. A review of 30 cases. Am J Dis Child 1978; 132:278.
- Sturzenegger MH, Meienberg O. Basilar artery migraine: a follow-up study of 82 cases. Headache 1985; 25:408.
- BICKERSTAFF ER. Impairment of consciousness in migraine. Lancet 1961; 2:1057.
- Olsson JE. Neurotologic findings in basilar migraine. Laryngoscope 1991; 101:1.
- Eviatar L. Vestibular testing in basilar artery migraine. Ann Neurol 1981; 9:126.
- Muellbacher W, Mamoli B. Prolonged impaired consciousness in basilar artery migraine. Headache 1994; 34:282.
- Sulkava R, Kovanen J. Locked-in syndrome with rapid recovery: a manifestation of basilar artery migraine? Headache 1983; 23:238.
- Solomon GD, Spaccavento LJ. Lateral medullary syndrome after basilar migraine. Headache 1982; 22:171.
- Maytal J, Libman RB, Lustrin ES. Basilar artery migraine and reversible imaging abnormalities. AJNR Am J Neuroradiol 1998; 19:1116.
- Baron EP, Tepper SJ, Mays M, Cherian N. Acute treatment of basilar-type migraine with greater occipital nerve blockade. Headache 2010; 50:1057.
- Kaniecki RG. Basilar-type migraine. Curr Pain Headache Rep 2009; 13:217.
- Klapper J, Mathew N, Nett R. Triptans in the treatment of basilar migraine and migraine with prolonged aura. Headache 2001; 41:981.
- Evans RW, Lipton RB. Topics in migraine management: a survey of headache specialists highlights some controversies. Neurol Clin 2001; 19:1.
- Bardwell A, Trott JA. Stroke in migraine as a consequence of propranolol. Headache 1987; 27:381.
- Bahemuka M. Basilar artery migraine in a child: excellent response to propranolol. East Afr Med J 1981; 58:75.
- Evans RW, Linder SL. Management of basilar migraine. Headache 2002; 42:383.
- Lewis D, Paradiso E. A double-blind, dose comparison study of topiramate for prophylaxis of basilar-type migraine in children: a pilot study. Headache 2007; 47:1409.
- Pascual J, Caminero AB, Mateos V, et al. Preventing disturbing migraine aura with lamotrigine: an open study. Headache 2004; 44:1024.
- Steiner TJ, Findley LJ, Yuen AW. Lamotrigine versus placebo in the prophylaxis of migraine with and without aura. Cephalalgia 1997; 17:109.
- Swanson JW, Vick NA. Basilar artery migraine 12 patients, with an attack recorded electroencephalographically. Neurology 1978; 28:782.
- Termine C, Ferri M, Livetti G, et al. Migraine with aura with onset in childhood and adolescence: long-term natural history and prognostic factors. Cephalalgia 2010; 30:674.