What is Basilar Migraine?
A basilar migraine is a type of migraine that largely affects the brainstem, the part of the brain connecting the spinal cord to the cerebral hemisphere. It was first identified by Bickerstaff in 1961 and goes by many names such as basilar artery migraine, brainstem migraine, vertebrobasilar migraine, and Bickerstaff migraine. Initially, it was believed that this migraine was caused by the contraction of the basilar artery. However, current understanding indicates there’s no specific evidence linking it to any vascular problems, and it is thought to stem from the activation of nerves in the brainstem. Accordingly, this form of migraine is now classified as a “migraine with brainstem aura.”
An “aura” refers to temporary sensory signs and symptoms that a person experiences just before or during a migraine attack. Approximately one in four migraine sufferers experiences these typical aura symptoms. The basilar migraine is a rare type of migraine with aura, seen with symptoms emanating from the brainstem or both halves of the brain simultaneously.
What Causes Basilar Migraine?
The exact cause of migraine with brainstem aura is still unknown. Just like with other migraines, things in the environment can play a part. Some believe there might be a link with genetics, but there’s no confirmed connection yet. Common triggers that cause these migraines, similar to other types, are things like strong smells, loud noises, changes in weather, too much or too little sleep, high stress, intense physical activity, birth control pills, or certain foods and beverages.
These foods include cheese, caffeine, alcohol, and food preservatives like monosodium glutamate (MSG). It’s important to note these triggers or causes are as per various studies, but exact causes can vary between individuals.
Risk Factors and Frequency for Basilar Migraine
While exact numbers of how many people get it are unclear, it’s known that this condition tends to affect females more than males. It can happen at any age, but it’s more frequently seen in teenagers and young adults. Usually, it first appears when someone is between 7 to 20 years old.
Signs and Symptoms of Basilar Migraine
Brainstem aura is associated with various symptoms like dizziness, difficulty speaking, double vision, ringing in the ears, diminished hearing, loss of balance, confusion, and in some cases, fainting. The most frequently observed symptom is dizziness. Additionally, many individuals also experience usual aura symptoms such as light flashes, vision loss, tingling or numbness, and challenges with language like trouble finding words, difficulty understanding language, and problems with reading. In some scenarios, individuals may experience anxiety and hyperventilation, which can result in a misdiagnosis. It’s important to note that all these aura symptoms are reversible. They can persist for a few minutes up to an hour and are often followed by a headache at the back of the head that can last for several hours or even days. In rare cases, a brainstem aura migraine can occur without a headache. Injury-like symptoms, such as mood changes, irritability, fatigue, nausea, and neck pain, should not be mixed up with aura symptoms. Also, issues like weakness, paralysis, or loss of vision in one eye are not typical of brainstem aura migraine and require further medical evaluation.
Brainstem aura symptoms can be quite frightening, especially when first experienced or before a definite diagnosis is given. They might resemble severe health conditions like strokes, tumors, or infections, so it’s crucial to get medical help if it’s your first time experiencing these symptoms or if their severity or frequency changes. However, these migraine symptoms, though worrying, are usually not harmful as they can be completely reversed.
The International Classification of Headache Disorders has provided the below criteria for diagnosing basilar migraine:
- (A) Symptoms not attributed to another disorder
- (B) At least 2 attacks that fulfill criteria C, D, or E
- (C) Aura with more than one of the following symptoms: difficulty speaking, dizziness, ringing in the ears, hearing impairment, double vision, lack of coordination, a decrease in the level of consciousness, tingling or numbness on both sides, with no symptoms related to movement or retinas, and completely reversible symptoms
- (D) At least one of the following: At least 1 aura symptom occurring gradually over 5 minutes or more and/or 2 or more symptoms occurring in succession over 5 minutes or more, each aura symptom lasts more than 5 minutes, but less than 60 minutes, at least 1 aura symptom is unilateral
- (E) A migraine without aura begins during the aura or within 1 hour
Testing for Basilar Migraine
Doctors typically use brain imaging techniques, such as MRI, MRA or CT angiography, to eliminate the possibility of other medical conditions like stroke, abnormal blood vessel connections (AV malformations), and tumors. An EEG, which records the electrical activity of the brain, is used when there’s a need to rule out seizures, particularly when the patient is confused or has a decreased level of consciousness. In some rare instances, a patient might be required to undergo 24-hour Holter monitoring, a test that records a patient’s heart activity, to rule out irregular heart rhythms (arrhythmias).
Treatment Options for Basilar Migraine
When someone has an acute (sudden) basilar migraine attack, it’s usually treated using specific types of painkillers known as NSAIDs, along with medications that prevent nausea and vomiting, such as prochlorperazine or metoclopramide. The early symptoms (known as “aura” symptoms) are often used as an early warning sign to start treating the migraine as quickly as possible.
In earlier clinical trials, two types of migraine treatments, triptans and ergotamines, were not included. Therefore, there’s not much information about how effective they could be. However, some recent studies have suggested these medications might improve headaches in basilar migraine patients. Some experts think these drugs could be potentially beneficial, much like they are in treating migraines with a typical aura. However, traditionally these meds have been avoided in basilar migraines due to concerns they could increase the risk of reduced blood flow to the brain (cerebral ischemia). At this point, the safety and usefulness of triptans and ergotamines for basilar migraines are not definitively known, as more data is needed.
In terms of preventing basilar migraines, the strategies are generally the same as those used for other types of migraines. It’s crucial to identify and, if possible, avoid the things that trigger the migraine. Keeping a headache diary can be useful in tracking the frequency, duration, and severity of symptoms, and in pinpointing triggers. Making certain lifestyle changes, like adjusting diet, managing stress, and getting regular exercise, can help prevent migraine attacks. Patients who have regular, severely disabling headaches should consider preventative treatment.
For preventing migraines with aura symptoms associated with the brainstem, medications such as verapamil and topiramate are most commonly used. Propranolol is usually avoided because it can affect the blood flow in the brain.
Non-drug treatments like relaxation techniques, acupuncture, massage, cognitive behavior therapy, and biofeedback can also be beneficial in preventing migraines, like with other types of migraines.
What else can Basilar Migraine be?
A basilar migraine can look similar to a hemiplegic migraine and a migraine that comes with a common aura. Before a doctor can definitively say a person has a basilar migraine, there are several other conditions that must be ruled out. This might include Meniere’s disease, an inner ear disorder that can affect balance and hearing, vestibular diseases, which are conditions that affect balance and eye movements, and transient ischemic attack, which is like a mini-stroke that usually doesn’t cause permanent damage. Doctors also need to rule out a stroke, abnormalities in the connections within the brain (brainstem atrioventricular malformation), brain tumors, and meningitis, which is an infection of the membranes that surround the brain and spinal cord.
What to expect with Basilar Migraine
Brainstem aura migraines can be more challenging to deal with than regular migraines or migraines with typical aura. This difficulty comes from the increased intensity and longer-lasting symptoms. As people age, the frequency of brainstem aura migraines decreases, and the migraines often become more typical in their patterns.
There’s a slightly higher risk of suffering a stroke for those who experience migraines with aura compared to those without aura. However, there’s no concrete evidence to suggest that brainstem aura migraines lead to a higher stroke risk than regular aura migraines.
It’s also important to note that smoking and the use of birth control pills containing estrogen can further raise the risk of a stroke. Therefore, appropriate adjustments to these risk factors should be emphasized for everyone.
Possible Complications When Diagnosed with Basilar Migraine
If patients suddenly faint during an aura, they may end up falling.
Preventing Basilar Migraine
The pharmacist’s role includes advising patients about the best medicines to help control their headaches. They also need to explain how to handle nausea and vomiting, which are often associated with headaches. Patients must understand how crucial it is for them to consistently take their medications if they want to get rid of the headache.
Since managing a headache can be tough after it starts, it’s important to focus on prevention. The pharmacist and the patient’s primary healthcare provider should guide the patient in making lifestyle changes and avoiding things that cause headaches. Keeping a ‘headache diary’ to record symptoms and triggers can be helpful.
Promoting a healthy lifestyle, which includes a balanced diet, regular physical activity, plenty of sleep, and stress management, can reduce the chances of experiencing a basilar migraine. Not skipping meals and setting regular meal times are also important, as a missed meal can set off a migraine.
Lastly, patients should be made aware that depending solely on natural remedies or herbs for pain relief might not be the best idea. This is because there isn’t much scientific proof to support their effectiveness in relieving pain.
