The similarities and differences of migraine with aura and migraine without aura: a preliminary study
R Ranson, H Igarashi, EA MacGregor, M Wilkinson
Cephalalgia Ranson R, Igarashi H, MacGregor EA, Wilkinson M. The similarities and differences of migraine with aura and migraine without aura: a preliminary study. Cephalalgia 1991;11:18992. Oslo. ISSN 0333-1024 A preliminary study was undertaken to provide clinical evidence to support the hypothesis that: "Migraine with aura, migraine without aura and aura alone are the same condition, which differ in degree rather than pathophysiology." At the City of London Migraine Clinic, 50 patients consecutively attending the clinic with a past or present history of migraine with aura were questioned. Of the 50 patients questioned 36 (70%) had a combination of migraine with aura, migraine without aura and/or aura alone; i.e. 70% had had more than one type of migraine attack. The duration, severity and frequency of attacks did not differ between migraine with and migraine without aura. Conclusion-the results support the hypothesis that migraine with and migraine without aura, and aura alone are not separate conditions, because: (1) most patients suffer from more than one type of migraine attack; (2) there are no significant differences in the characteristics of the migraine attacks in the different groups; (3) there are no significant differences in the characteristics of the subjects. • Migraine, aura R Ranson, EA MacGregor, M Wilkinson, The City of London Migraine Clinic, 22 Charterhouse Square, London EC1M 6DX; H Igarashi, Department of Medicine, School of Medicine, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa, Japan (22E); Correspondence to R Ranson; Accepted 25 June 1991 Migraine has until recently been classified as classic and common migraine. In 1988 a new classification was proposed by the International Headache Society (1). Classic and common migraine remain as distinct classifications, although they have been renamed respectively migraine with aura and migraine without aura. Migraine aura without headache (previously called aura alone) is included in this classification as a subgroup of migraine with aura. To avoid confusion and for ease of understanding, the old terms classic and common migraine, and aura alone are used in this paper. The phenomenon of spreading cortical depression was first proposed by Leao in 1944 (2). Following further research the relationship between regional cerebral blood flow and spreading depression in animals was compared to the known clinical phenomenon of migraine in man. Olesen, Larsen and Lauritzen measured serial regional blood flow in six cases of classic migraine utilizing 133Xe intra-carotid injection (3). They observed gradual spreading oligaemia. Olesen et al. (4) also measured regional cerebral blood flow in eight patients with common migraine by the same method and found no significant focal or global changes in regional cerebral blood flow. They concluded that each of the forms of migraine, classic and common, were different with respect to haemodynamic changes and therefore must have a different pathogenesis. They suggested that the spreading depression of Leao might be a possible cause of classic migraine. A recent study by Kobari et al. (5) found hyperperfusion involving not only the cerebral cortex but also subcortical structures including the thalamus, basal ganglia and subcortical white matter; no significant differences in the degree or pattern of hyperperfusion during headaches was found when comparing patients with classic and common migraine. This study suggests a common pathogenesis for classic and common migraine and disputes previous evidence from studies reporting spreading oligaemia or spreading cortical depression and thus different aetiologies (3, 6-8). Differences of opinion exist as to whether or not classic and common migraine are different conditions with different pathophysiologies, or whether they are the same condition differing only in degree, and with the same pathophysiology (9, 10). This study examines and compares features of both classic and common migraine in patients attending the City of London Migraine Clinic in an attempt to elucidate this problem. Methods
Using criteria laid down by the International Headache Society for diagnosing and classifying migraine 1988 (1), fifty patients consecutively attending the City of London Migraine Clinic, with a past or current history of classic migraine, were questioned by doctors working at the clinic. A detailed history was taken and all patients were fully examined to exclude other medical or neurological diseases. For each subject we recorded the age of their first migraine attack and the age of their first
Table 1. Subject data.
No. of subjects
Male Female Mean age at study Male (years) Female Mean age at onset Male of migraine (years) Female
Group 2 Classical Group 1 migraine and/ Classical or aura alone, migraine and/ and common or aura alone migraine 6 5 19 20 34.0 34.8 35.3 38.7 19.6 (SD ± 10.7) 14.8 (SD ± 2.4) 15.5 (SD ± 8.8) 17.5 (SD ± 10.9)
aura if this was different; whether or not they had had, or did have, different types of migraine attack, i.e. migraine without aura or aura alone, the frequency, duration and severity of each type of migraine attack, including a description of their aura and its duration. Results
Fifty patients were interviewed (39 women and 11 men). The age range of women was 18-72 years (mean 37 years ± SD 13.11), and the age range of men 18-59 years (mean 34.4 years ± SD 13.15). All patients had a history of classic migraine or aura alone, and this was the criterion for them being entered into the study. Of the 50 subjects questioned about their present attacks, 17 had only classic migraine, 16 had both classic and common migraine, 9 had classic and common migraine and aura alone, 6 had classic migraine and aura alone, and 2 had only aura, although one of these subjects had had classic migraine in the past. The subjects were divided into two groups as shown in Table 1. Subjects in group 1 were those suffering from classic migraine, and/or aura alone; subjects in group 2 were those suffering from classic migraine and/or aura alone, and common migraine. Fourteen subjects had only ever had classic migraine. A further three patients, all of whom were female, currently had only classic migraine, but were uncertain whether or not they had had an aura with their first migraine attack: One remembered the onset of her migraine at the age of 4 years and her first aura aged 17 years, the second gave an onset at the age of 2 years with her first aura aged 5 years, and the third had no definite recollection. One further subject had only ever had aura alone. Twenty-five (50 %) of the subjects had experienced both classic and common migraine, but had not had attacks of aura alone. Overall, 70% had experienced classic, common and or aura alone. There was no significant difference in the age of migraine onset between the two groups of subjects or between the sexes, as shown in Table 2. There was no significant difference in the duration or frequency of individual classic and common migraine attacks between the two groups or between the sexes. Furthermore, there were no significant differences in the duration or frequency of classic migraine attacks between the two groups. There was no significant difference in the duration of aura between the two groups of patients. Six patients were uncertain of the duration of their aura. We also collected data on the following, to see: (1) if the severity of the headache varied with the site of the headache in each individual; (2) if the severity of the headache varied between attacks of classic migraine and common migraine; (3) if there was any relationship between the side of the aura and the side of the headache (Table 3); (4) if there was any relationship between the side of the aura and whether the subject was left or right handed. No relationship was found between any of the above parameters. All subjects were asked if they had migraine attacks on waking, and, if so, whether or not these were preceded by an aura or dream of an aura. Thirty subjects had some migraine attacks on waking, 13 of these had an aura on waking and 4 had dreams of an aura preceding these waking migraine attacks. Other symptoms associated with migraine attacks were also noted. Twenty-six subjects, (52%), complained of other symptoms, [23 of the 39 females (59%), and 4 of the 11 males (36%)]. Twenty subjects complained of numbness, 4 of numbness associated with other symptoms including speech disturbance and clumsiness, 1 subject reported loss of power and numbness down one side when young, and 1 subject reported speech disturbance alone. Ninety-six percent of those subjects who experienced other symptoms had numbness as one of those symptoms. The ratio of men to women in the study was approximately 1:4. All male subjects had classical migraine at the onset. Subsequently 5 developed different types of migraine attack, 3 developed common migraine, and 2 developed common migraine and aura alone. Despite developing different types of migraine, all continued to have attacks of migraine with aura. Out of 39 women in the study the onset varied in the following way. Twenty-five (64%) had classical migraine at the onset, 8 had an onset of common migraine, 4 were uncertain, and 2 had an onset of aura alone. From the 25 who had an onset of classical migraine, 16 developed other types of migraine, 5 common migraine and aura alone, 5 aura alone, and 6 common migraine. Only 9 continued to have solely classical migraine. In summary, there was no significant difference in the characteristics of migraine attack (duration,
Table 2. Characteristics of migraine attacks. Group 1 Group 2 Classical migraine and/or Classical migraine and/or aura aura alone alone, and common migraine Duration of attacks of classicalMean 26.1 (SD ± 26.0) 28.5 (SD ± 28.3) migraine (h) Range 2-120 3-120 Duration of attacks of common Mean -26.9 (SD ± 27.0) migraine (h) Range 2.5-120 Duration of aura (min) Mean 25 (SD ± 15) 26.0 (SD ± 24.3) Range 10-20 5-20 Frequency of attacks of classical Mean 2.6 attacks per month (SD ± 3.2) 3.6 attacks per month (SD ± 3.4) migraine Range 12 per month-8 per annum 15 per month-3 per annum Frequency of attacks of Mean 2.6 attacks per month (SD ± 2.7) common migraine Range 10 per month-4 per annum Table 3. Side aura in relation to side of headache. Relationship of aura to headache No association between side of headache and side of aura Right-sided aura always associated with left-sided headache or Left-sided aura always associated with right-sided headache Right-sided aura always associated with right-sided headache or Left-sided aura always associated with left-sided headache Headache always on the same side aura can be left- or right-sided No response Aura alone
No. of subjects n = 50 13 7
10
4 15 1
frequency, severity, characteristics and duration of aura) between the two groups; neither was there any significant difference between the groups of subjects themselves (age of onset of migraine, current age). Discussion
Our results suggest that classic and common migraine are one condition, the difference being in the severity of the symptoms rather than in the basic pathophysiology. In our opinion the types of migraine attack are not mutually exclusive, and, as is shown in this study, most individuals have a combination of types. There may be progression from one type to another or an individual can have more than one type with equal frequency. In our study the characteristics of the attacks of classic and common migraine were similar, as were the characteristics of the subjects in the two groups. In our sample 50% of subjects suffered from both classic and common migraine. This evidence must surely cast doubt on migraine with and without aura, being different conditions, and having different pathophysiologies. The findings of this preliminary study highlight areas of research which need further investigation and raise certain questions. These include: 1. Migraines which occur on waking may be attacks of migraine without aura, or the patients may be sleeping through the aura and waking only when the headache begins, i.e. they are having attacks of migraine with aura. 2. There is a suggestion from these figures that the type of first attack, and therefore onset of migraine, differs between the sexes. All of the men in our sample recalled an aura in their first migraine attack compared to only 65% of women. Migraine can be compared to a chameleon, it has numerous manifestations in the same way that a chameleon changes its colour, but we do not then classify it as a different species! References
1.
Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8(suppl 7):1-96
2.
Leao AAP. Spreading depression of activity in the cerebral cortex. Neurophysiol 1944;7:359-90
3.
Olesen J, Larsen B, Lauritzen M. Focal hyperaemia followed by spreading oligaemia and impaired activation of regional cerebral blood flow in classic migraine. Ann Neurol 1981;9:344-52
4.
Olesen J, Tfelt-Hansen P, Henriksen L, Larsen B. The common migraine attack may not be initiated by cerebral ischaemia. Lancet 1981;(ii):438-40
5.
Kobari M, Meyer JS, Ichijo M, Imai A, Oravez WT. Hyperperfusion of cerebral cortex, thalamus and basal ganglia during spontaneously occurring migraine headaches. Headache 1988;29:282-9
6.
Lauritzen M, Olesen J. Regional cerebral blood flow during migraine attacks by Xe-133 inhalation and emission tomography. Brain 1984;107:447-61
7.
Lauritzen M, Jorgensen MB, Diemer NH, Gjedde A, Hansen AJ. Persistent oligaemia of rat cerebral cortex in the wake of spreading depression. Ann Neurol 1982;12:469-74
8.
Lauritzen M, Olsen TS, Lassen NA, Paulson OB. Changes in regional cerebral blood flow during the course of classic migraine attacks. Ann Neurol 1983;13;633-41
9.
Wilkinson M, Blau JN. Are classical and common migraine different entities. Headache 1985;25:211-12
10.
Olesen J. Are classical and common migraine different entities. Headache 1985;25:213
R Ranson, H Igarashi, EA MacGregor, M Wilkinson
Cephalalgia Ranson R, Igarashi H, MacGregor EA, Wilkinson M. The similarities and differences of migraine with aura and migraine without aura: a preliminary study. Cephalalgia 1991;11:18992. Oslo. ISSN 0333-1024 A preliminary study was undertaken to provide clinical evidence to support the hypothesis that: "Migraine with aura, migraine without aura and aura alone are the same condition, which differ in degree rather than pathophysiology." At the City of London Migraine Clinic, 50 patients consecutively attending the clinic with a past or present history of migraine with aura were questioned. Of the 50 patients questioned 36 (70%) had a combination of migraine with aura, migraine without aura and/or aura alone; i.e. 70% had had more than one type of migraine attack. The duration, severity and frequency of attacks did not differ between migraine with and migraine without aura. Conclusion-the results support the hypothesis that migraine with and migraine without aura, and aura alone are not separate conditions, because: (1) most patients suffer from more than one type of migraine attack; (2) there are no significant differences in the characteristics of the migraine attacks in the different groups; (3) there are no significant differences in the characteristics of the subjects. • Migraine, aura R Ranson, EA MacGregor, M Wilkinson, The City of London Migraine Clinic, 22 Charterhouse Square, London EC1M 6DX; H Igarashi, Department of Medicine, School of Medicine, Kitasato University, 1-15-1 Kitasato, Sagamihara, Kanagawa, Japan (22E); Correspondence to R Ranson; Accepted 25 June 1991 Migraine has until recently been classified as classic and common migraine. In 1988 a new classification was proposed by the International Headache Society (1). Classic and common migraine remain as distinct classifications, although they have been renamed respectively migraine with aura and migraine without aura. Migraine aura without headache (previously called aura alone) is included in this classification as a subgroup of migraine with aura. To avoid confusion and for ease of understanding, the old terms classic and common migraine, and aura alone are used in this paper. The phenomenon of spreading cortical depression was first proposed by Leao in 1944 (2). Following further research the relationship between regional cerebral blood flow and spreading depression in animals was compared to the known clinical phenomenon of migraine in man. Olesen, Larsen and Lauritzen measured serial regional blood flow in six cases of classic migraine utilizing 133Xe intra-carotid injection (3). They observed gradual spreading oligaemia. Olesen et al. (4) also measured regional cerebral blood flow in eight patients with common migraine by the same method and found no significant focal or global changes in regional cerebral blood flow. They concluded that each of the forms of migraine, classic and common, were different with respect to haemodynamic changes and therefore must have a different pathogenesis. They suggested that the spreading depression of Leao might be a possible cause of classic migraine. A recent study by Kobari et al. (5) found hyperperfusion involving not only the cerebral cortex but also subcortical structures including the thalamus, basal ganglia and subcortical white matter; no significant differences in the degree or pattern of hyperperfusion during headaches was found when comparing patients with classic and common migraine. This study suggests a common pathogenesis for classic and common migraine and disputes previous evidence from studies reporting spreading oligaemia or spreading cortical depression and thus different aetiologies (3, 6-8). Differences of opinion exist as to whether or not classic and common migraine are different conditions with different pathophysiologies, or whether they are the same condition differing only in degree, and with the same pathophysiology (9, 10). This study examines and compares features of both classic and common migraine in patients attending the City of London Migraine Clinic in an attempt to elucidate this problem. Methods
Using criteria laid down by the International Headache Society for diagnosing and classifying migraine 1988 (1), fifty patients consecutively attending the City of London Migraine Clinic, with a past or current history of classic migraine, were questioned by doctors working at the clinic. A detailed history was taken and all patients were fully examined to exclude other medical or neurological diseases. For each subject we recorded the age of their first migraine attack and the age of their first
Table 1. Subject data.
No. of subjects
Male Female Mean age at study Male (years) Female Mean age at onset Male of migraine (years) Female
Group 2 Classical Group 1 migraine and/ Classical or aura alone, migraine and/ and common or aura alone migraine 6 5 19 20 34.0 34.8 35.3 38.7 19.6 (SD ± 10.7) 14.8 (SD ± 2.4) 15.5 (SD ± 8.8) 17.5 (SD ± 10.9)
aura if this was different; whether or not they had had, or did have, different types of migraine attack, i.e. migraine without aura or aura alone, the frequency, duration and severity of each type of migraine attack, including a description of their aura and its duration. Results
Fifty patients were interviewed (39 women and 11 men). The age range of women was 18-72 years (mean 37 years ± SD 13.11), and the age range of men 18-59 years (mean 34.4 years ± SD 13.15). All patients had a history of classic migraine or aura alone, and this was the criterion for them being entered into the study. Of the 50 subjects questioned about their present attacks, 17 had only classic migraine, 16 had both classic and common migraine, 9 had classic and common migraine and aura alone, 6 had classic migraine and aura alone, and 2 had only aura, although one of these subjects had had classic migraine in the past. The subjects were divided into two groups as shown in Table 1. Subjects in group 1 were those suffering from classic migraine, and/or aura alone; subjects in group 2 were those suffering from classic migraine and/or aura alone, and common migraine. Fourteen subjects had only ever had classic migraine. A further three patients, all of whom were female, currently had only classic migraine, but were uncertain whether or not they had had an aura with their first migraine attack: One remembered the onset of her migraine at the age of 4 years and her first aura aged 17 years, the second gave an onset at the age of 2 years with her first aura aged 5 years, and the third had no definite recollection. One further subject had only ever had aura alone. Twenty-five (50 %) of the subjects had experienced both classic and common migraine, but had not had attacks of aura alone. Overall, 70% had experienced classic, common and or aura alone. There was no significant difference in the age of migraine onset between the two groups of subjects or between the sexes, as shown in Table 2. There was no significant difference in the duration or frequency of individual classic and common migraine attacks between the two groups or between the sexes. Furthermore, there were no significant differences in the duration or frequency of classic migraine attacks between the two groups. There was no significant difference in the duration of aura between the two groups of patients. Six patients were uncertain of the duration of their aura. We also collected data on the following, to see: (1) if the severity of the headache varied with the site of the headache in each individual; (2) if the severity of the headache varied between attacks of classic migraine and common migraine; (3) if there was any relationship between the side of the aura and the side of the headache (Table 3); (4) if there was any relationship between the side of the aura and whether the subject was left or right handed. No relationship was found between any of the above parameters. All subjects were asked if they had migraine attacks on waking, and, if so, whether or not these were preceded by an aura or dream of an aura. Thirty subjects had some migraine attacks on waking, 13 of these had an aura on waking and 4 had dreams of an aura preceding these waking migraine attacks. Other symptoms associated with migraine attacks were also noted. Twenty-six subjects, (52%), complained of other symptoms, [23 of the 39 females (59%), and 4 of the 11 males (36%)]. Twenty subjects complained of numbness, 4 of numbness associated with other symptoms including speech disturbance and clumsiness, 1 subject reported loss of power and numbness down one side when young, and 1 subject reported speech disturbance alone. Ninety-six percent of those subjects who experienced other symptoms had numbness as one of those symptoms. The ratio of men to women in the study was approximately 1:4. All male subjects had classical migraine at the onset. Subsequently 5 developed different types of migraine attack, 3 developed common migraine, and 2 developed common migraine and aura alone. Despite developing different types of migraine, all continued to have attacks of migraine with aura. Out of 39 women in the study the onset varied in the following way. Twenty-five (64%) had classical migraine at the onset, 8 had an onset of common migraine, 4 were uncertain, and 2 had an onset of aura alone. From the 25 who had an onset of classical migraine, 16 developed other types of migraine, 5 common migraine and aura alone, 5 aura alone, and 6 common migraine. Only 9 continued to have solely classical migraine. In summary, there was no significant difference in the characteristics of migraine attack (duration,
Table 2. Characteristics of migraine attacks. Group 1 Group 2 Classical migraine and/or Classical migraine and/or aura aura alone alone, and common migraine Duration of attacks of classicalMean 26.1 (SD ± 26.0) 28.5 (SD ± 28.3) migraine (h) Range 2-120 3-120 Duration of attacks of common Mean -26.9 (SD ± 27.0) migraine (h) Range 2.5-120 Duration of aura (min) Mean 25 (SD ± 15) 26.0 (SD ± 24.3) Range 10-20 5-20 Frequency of attacks of classical Mean 2.6 attacks per month (SD ± 3.2) 3.6 attacks per month (SD ± 3.4) migraine Range 12 per month-8 per annum 15 per month-3 per annum Frequency of attacks of Mean 2.6 attacks per month (SD ± 2.7) common migraine Range 10 per month-4 per annum Table 3. Side aura in relation to side of headache. Relationship of aura to headache No association between side of headache and side of aura Right-sided aura always associated with left-sided headache or Left-sided aura always associated with right-sided headache Right-sided aura always associated with right-sided headache or Left-sided aura always associated with left-sided headache Headache always on the same side aura can be left- or right-sided No response Aura alone
No. of subjects n = 50 13 7
10
4 15 1
frequency, severity, characteristics and duration of aura) between the two groups; neither was there any significant difference between the groups of subjects themselves (age of onset of migraine, current age). Discussion
Our results suggest that classic and common migraine are one condition, the difference being in the severity of the symptoms rather than in the basic pathophysiology. In our opinion the types of migraine attack are not mutually exclusive, and, as is shown in this study, most individuals have a combination of types. There may be progression from one type to another or an individual can have more than one type with equal frequency. In our study the characteristics of the attacks of classic and common migraine were similar, as were the characteristics of the subjects in the two groups. In our sample 50% of subjects suffered from both classic and common migraine. This evidence must surely cast doubt on migraine with and without aura, being different conditions, and having different pathophysiologies. The findings of this preliminary study highlight areas of research which need further investigation and raise certain questions. These include: 1. Migraines which occur on waking may be attacks of migraine without aura, or the patients may be sleeping through the aura and waking only when the headache begins, i.e. they are having attacks of migraine with aura. 2. There is a suggestion from these figures that the type of first attack, and therefore onset of migraine, differs between the sexes. All of the men in our sample recalled an aura in their first migraine attack compared to only 65% of women. Migraine can be compared to a chameleon, it has numerous manifestations in the same way that a chameleon changes its colour, but we do not then classify it as a different species! References
1.
Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8(suppl 7):1-96
2.
Leao AAP. Spreading depression of activity in the cerebral cortex. Neurophysiol 1944;7:359-90
3.
Olesen J, Larsen B, Lauritzen M. Focal hyperaemia followed by spreading oligaemia and impaired activation of regional cerebral blood flow in classic migraine. Ann Neurol 1981;9:344-52
4.
Olesen J, Tfelt-Hansen P, Henriksen L, Larsen B. The common migraine attack may not be initiated by cerebral ischaemia. Lancet 1981;(ii):438-40
5.
Kobari M, Meyer JS, Ichijo M, Imai A, Oravez WT. Hyperperfusion of cerebral cortex, thalamus and basal ganglia during spontaneously occurring migraine headaches. Headache 1988;29:282-9
6.
Lauritzen M, Olesen J. Regional cerebral blood flow during migraine attacks by Xe-133 inhalation and emission tomography. Brain 1984;107:447-61
7.
Lauritzen M, Jorgensen MB, Diemer NH, Gjedde A, Hansen AJ. Persistent oligaemia of rat cerebral cortex in the wake of spreading depression. Ann Neurol 1982;12:469-74
8.
Lauritzen M, Olsen TS, Lassen NA, Paulson OB. Changes in regional cerebral blood flow during the course of classic migraine attacks. Ann Neurol 1983;13;633-41
9.
Wilkinson M, Blau JN. Are classical and common migraine different entities. Headache 1985;25:211-12
10.
Olesen J. Are classical and common migraine different entities. Headache 1985;25:213
