Headache - Basilar Migraine
Related Subjects:Migraine
|Basilar Migraine
|Cluster Headaches
|Sumatriptan
|Tension Headache
|Analgesic Overuse Headache
|Headaches in General
🧠 About
- Basilar Migraine (Migraine with Brainstem Aura) is a rare migraine subtype affecting the brainstem and posterior circulation territories.
- Characterized by aura symptoms such as visual disturbance, vertigo, tinnitus, dysarthria, or ataxia without motor weakness.
- In atypical cases, always consider serious differentials such as vertebral artery dissection, posterior circulation stroke, or CNS demyelination.
- Most common in adolescent girls and young women, but can occur across age groups.
⚡ Aetiology
- Triggered by cortical spreading depression → wave of depolarisation disrupting brainstem and occipital cortex.
- Involves trigeminovascular activation → neurogenic inflammation + vasodilation in posterior circulation.
- Shares triggers with other migraine types:
- Stress 😥
- Hormonal changes (esp. menstruation) ♀️
- Certain foods (tyramine, nitrates, MSG) 🍷🥓
- Sleep disturbance 😴
- Bright lights or loud noise 💡🔊
📋 Diagnostic Criteria (ICHD-3)
- At least two of the following reversible brainstem symptoms (no motor weakness):
- 👁 Visual disturbances (bilateral field defects, scotomas)
- 🗣 Dysarthria
- 🎢 Vertigo
- 👂 Tinnitus or hypoacusis
- 👓 Diplopia
- 🚶 Ataxia
- ✨ Bilateral paraesthesia
- 😴 Decreased consciousness
- Aura usually lasts 5–60 mins, followed by occipital throbbing headache ± nausea/vomiting 🤢.
- Must not be better accounted for by another diagnosis.
🔎 Clinical Features
- Severe throbbing occipital headache, often after aura.
- Aura without headache (acephalgic migraine) may occur.
- Triggers include postural change, exertion, and stress.
- Episodes may mimic TIA or seizure → careful history is essential.
🧾 Differential Diagnosis
- 🩸 Vertebral artery dissection (especially with neck trauma + unilateral signs)
- 🧠 Posterior circulation stroke
- ⚡ Epilepsy
- 🧩 Chiari malformation
- 🌐 Multiple sclerosis
🧪 Investigations
- MRI brain – rule out stroke, demyelination, or dissection.
- MRA/CTA – assess vertebrobasilar circulation and aneurysms.
- EEG – if seizure is a differential.
- Bloods – ESR/CRP, coagulation profile, metabolic screen.
- LP – if infection or SAH suspected.
💊 Management
- Acute therapy:
- ❌ Avoid triptans and ergotamines (risk of vasospasm in posterior circulation).
- ✔ Simple analgesia (ibuprofen, paracetamol).
- ✔ Antiemetics (e.g., metoclopramide) for nausea/vomiting.
- Preventive therapy:
- Beta-blockers (propranolol) 💊
- Calcium channel blockers (verapamil) 🩺
- Topiramate / valproate if frequent or refractory
- Lifestyle:
- Maintain regular sleep ⏰
- Avoid known triggers 🚫
- Encourage aerobic exercise 🏃♀️
- Patient education:
- Explain benign but disabling nature.
- Highlight red flags → sudden severe neuro deficit, persistent confusion, unilateral weakness (→ urgent stroke pathway).
📈 Prognosis
- Most improve with treatment + trigger avoidance.
- Rare complication: posterior circulation stroke → necessitates careful monitoring.
