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Journal of Family Practice, May, 1991 by Donald M. Pedersen, William M. Wilson, George L. White, Jr., Richard T. Murdock, Kathleen B. Digre
Migraine is described as a familial disorder characterized by recurrent headaches that are variable in intensity, frequency, and duration.[1] Attacks are usually unilateral but can also be bilateral and accompanied by throbbing pain, photophobia, phonophobia, nausea, and vomiting. Some migraines are preceded by, or are associated with, neurological and mood disturbances. All of the above characteristics, however, are not necessarily present in each attack, nor in each patient.[2]
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It has been suggested that the prevalence of migraine is probably markedly underestimated. Estimates range from 10% to 34% of the general population, with some authors reporting both age-related and sex-related differences. Prevalence appears to be highest among women and among young adults of both sexes. Patients with acephalgic migraine (migraine aura without headache) may represent as many as 3% of migraineurs.[3]
Case Report
A 40-year-old man presented for evaluation of a 12-year history of periodic visual disturbance. The disturbance which occurs approximately every 6 months, reportedly begins centrally as a small, bilateral, circular distortion, and then expands, over a 20-minute period, into an enlarging three-quarter circle of brightly colored and flickering lights described as being "similar to multiple small prisms laid side-by-side in semicircular fashion." The disturbance continues to enlarge until it grows out of the patient's field vision. There is no history of paresthesia, olfactory or auditory disturbance, nausea, vomiting, or headache preceding, during, or subsequent to the disturbance described. The patient also denies antecedent trauma or emotional stress. The episodes are reportedly always similar in nature, with an expanding scintillating scotoma and without subsequent headache. The patient's first episode, his most recent episode, and "a few" of the others have occurred after a 60-minute exercise period, which he performs consistently as a matter of his daily routine. There is a history of myopia, for correction of which soft contact lenses are used, and numerous vitreous floaters have been reported. The patient takes no medication, has no history of illicit drug use, and is otherwise healthy except for a history of mild seasonal allergic rhinitis. There is a family history of migraines.
A physical and neurologic examination of the patient was performed, and the findings were within normal limits. The diagnosis of migraine aura without headache was made. The patient was not placed on any specific therapeutic intervention. Since his episodes of scotoma occur only sporadically (every 4 to 6 months) and are not associated with additional symptomology, initiation of prophylaxis or abortive therapy was deemed inappropriate.
Long-term follow-up of the patient includes annual examination. He has been encouraged to keep a diary of visual phenomena, paying particular attention to activity, diet, and associated symptoms.
Discussion
The terms acephalgic migraine or migraine equivalents have been replaced within the Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain by the Headache Classification Committee of the International Headache Society. These previous designations have been replaced by the term migraine aura without headache, which describes migrainous events exclusively manifested by one of the neurological disturbances that usually precede or accompany the headache of classical migraine.
Approximately 20% of migraineurs may experience acephalgic attacks of migraine at one time or another.[1] Indeed, that various symptoms can occur in the absence of any headache has been noted for some time; in fact, visual phenomena were described as early as the 12th century. it is not, therefore, surprising that vivid accounts of migraine accompaniments exist throughout history, since the scintillating scotoma is the most frequently occurring visual symptom in migraine with or without headache. Terms such as "sparkling, dancing lights," "vibrating light," "wiggly line," "shimmering, like heat off a hot road," "jagged flashes," and "flickering light" are often used to describe this dramatic occurrence. Colors most often reported are red, gold or yellow, green, and blue or purple.[4]
While acephalgic migraine would fall into the category of migraine aura without headache, episodes of migraine aura without headache can occur in individuals with a history of classic migraine. When acephalgic migraine begins after the age of 40, the diagnosis must be suspect, since thrombotic transient ischemia can also be the cause. These patients have a history of classic migraine in younger years, then the headaches cease and the patients begin having what C.M. Fisher has called "late-life migraine accompaniments."[5,6] Since one must be careful to assure no other underlying pathology, extensive studies of the heart and vascular system are frequently needed to confirm this diagnosis. Pathophysiology
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