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(CEP)
[1–9] [PREPRINTER stage]
Original Article
Variability of clinical features in attacks of migraine with aura
Cephalalgia 0(0) 1–9 ! International Headache Society 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0333102415584601 cep.sagepub.com
Jakob M Hansen1, Peter J Goadsby2 and Andrew C Charles1 Abstract Background: There is significant variability in the clinical presentation of migraine, both among patients, and between attacks in an individual patient. We examined clinical features of migraine with aura in a large group of patients enrolled in a clinical trial, and compared retrospective migraine attack characteristics reported upon enrollment in the trial with those recorded prospectively in the trial. Methods: Patients with migraine (n ¼ 267) with typical visual aura in more than 30% of their attacks were enrolled from 16 centers for a clinical trial. Upon enrollment, patients provided a detailed retrospective description of the clinical features of their attacks of migraine. During the trial, clinical symptoms in migraine attacks starting with aura were recorded prospectively in 861 attacks. Results: Retrospectively reported visual aura symptoms were variable and often overlapping; the most common symptoms were dots or flashing lights, wavy or jagged lines, blind spots, and tunnel vision. Multiple patients reported more than one visual phenomenon. Approximately half of the patients reported nonvisual aura symptoms, the most common were numbness and tingling, followed by difficulty in recalling or speaking words. A significant percentage of patients also reported a change in olfaction. There were several inconsistencies between the features of prospectively recorded and retrospectively reported attacks. Headache, nausea, photophobia, and phonophobia were all less common in prospectively recorded attacks as compared with retrospective reporting. Nausea was prospectively recorded in only 51% of attacks and mostly with mild intensity. The occurrence and severity of nausea was reduced with advancing patient age. Phonophobia was not consistently recorded in conjunction with photophobia. Conclusion: These findings are consistent with variable involvement of different brain regions during a migraine attack. The variable occurrence of nausea, and phonophobia in conjunction with photophobia, both defining features of migraine, may be an important consideration in designing clinical studies of migraine in which prospectively recorded attacks are diagnosed based on these clinical features. Keywords Migraine aura, clinical characteristics, RCT, prospective recordings, cohort study, cortical spreading depression Date received: 9 February 2015; revised: 4 March 2015; 15 March 2015; accepted: 19 March 2015
Introduction Migraine is the most disabling (1) and prevalent neurological disorder with more than 80 million sufferers in Europe and the United States (US) alone (2). The clinical presentation of attacks of migraine varies considerably, both among patients and within each patient. While this variability is obvious in routine clinical practice it has not been extensively characterized prospectively, particularly for migraine with aura. Most reports of the clinical characteristics of migraine with aura are retrospective (3–9), and the available prospective studies (10–12) are based on a limited number of patients. This study uses data from a large prospective randomized clinical trial (13) to analyze the characteristics of migraine aura and other symptoms in migraine attacks
in a large cohort of patients with migraine with aura. We have previously reported based on this data that clinical features of migraine—headache, nausea, 1 Headache Research and Treatment Program, Department of Neurology, University of California Los Angeles, USA 2 Headache Group, Clinical Neurosciences and NIHR-Wellcome Trust Clinical Research Facility, King’s College London, UK
Corresponding author: Jakob M Hansen, MD, PhD, Danish Headache Center and Department of Neurology, Rigshospitalet, Glostrup, Faculty of Health Sciences, University of Copenhagen, Nordre Ringvej 57, DK-2600 Glostrup, Copenhagen, Denmark. Email: [email protected]
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(CEP)
[1–9] [PREPRINTER stage]
2 photophobia, and phonophobia—are commonly present during the aura phase of an attack (14). The diagnosis of migraine is based on patient reporting of attack features. However, some clinical studies of migraine, particularly clinical trials of preventive therapies, involve prospective documentation of migraine attacks. In these studies, variation of attack characteristics may represent a significant confounding factor. The goal of this study was two-fold: first, to describe the clinical features of migraine with typical aura in a large group of patients enrolled in a clinical trial, and secondly, to compare self-reported (retrospective) migraine symptoms to prospective recordings of attacks in the same patients.
Methods Patients aged 18–70 years and meeting International Classification of Headache Disorders, second edition (ICHD-II) criteria for migraine with typical visual aura (15) were recruited from 16 centers in the US for a double-blind, placebo-controlled trial of the therapeutic efficacy of single-pulse transcranial magnetic stimulation (sTMS) for attacks of migraine with aura (13). Patients were eligible for inclusion if they had a consistent history of migraine with visual aura of at least one year, one to eight migraine episodes per month and visual aura preceding the migraine for at least 30% of episodes, followed by moderate or severe headache in 90% of attacks. Key exclusion criteria were aura lasting for more than 60 minutes, presence of metal implants, headaches due to underlying pathology or trauma, and overuse of drugs for headaches or use of drugs that could confound interpretation of study results. Data from individual patients were summarized using frequency counts with percentages and descriptive statistics such as means and standard deviation. Statistical analyses were performed with SPSS 17.0 (Chicago, IL) for Windows. Five percent (p ¼ 0.05) was chosen as the level of significance.
Patient-delivered symptoms report Retrospective attack characteristics were collected on inclusion. Prospective data was recorded by patients in an electronic diary as soon as possible after aura began and always within one hour of aura onset. All prospective data in this analysis were collected before any treatment. Patients were asked to rate the most prevalent symptoms: headache, nausea, photophobia and phonophobia, on a four-point scale; 0 no symptoms; 1 mild; 2 moderate; and 3 severe. Less common symptoms and visual and nonvisual aura symptoms were dichotomized to yes/no responses.
Cephalalgia 0(0)
Standard protocol approvals, registrations, and patient consents All study centers provided institutional review board approval before study initiation, and all participants gave written informed consent. The trial was registered with ClinicalTrials.gov, number NCT00449540.
Results A total of 276 patients with migraine with aura were screened, and 267 enrolled in the study and provided the historical clinical attack data. The prospective part of the study consisted of a run-in phase (phase I) where 201 patients reported 456 attacks, and a treatment phase (phase II) where 164 patients were treated either with sTMS or sham stimulation and reported 405 attacks. In total, we report data from 861 prospectively recorded migraine attacks with aura (Figure 1). The majority of patients were female (81%) and Caucasian (87%). The mean age of onset was 17.8 years, mean duration of disease was 21.2 years with a diagnostic delay (time from migraine onset to diagnosis) of 6.2 years. There were no significant gender differences for the important demographic characteristics, except for attack duration (Table 1). Patient reports on the relation between menstruation and migraine were available from 151 women; a large minority (40%) reported that migraine attacks were related to the menstrual cycle, with attacks occurring within 2 to þ3 days of menstruation.
Aura symptoms Detailed reports of aura symptoms are based on retrospective patient reports (n ¼ 267). The aura symptoms for women and men did not differ, and pooled data are presented. As per the inclusion criteria, all 267 patients reported visual symptoms as part of their migraine aura. Most patients reported more than one visual aura symptom, (median 2, range 1–5). The most prevalent visual aura symptoms were dots or flashing lights, wavy or jagged lines and scotoma. Figure 2(a) demonstrates an overview of the different combinations of the most prevalent visual aura symptoms. Additional visual symptoms classified as aura included hallucinations (n ¼ 22), blurry vision (n ¼ 22), photopsia (n ¼ 14), halos (n ¼ 7), obscuration (n ¼ 4) and micropsia (n ¼ 1). Approximately half of the patients (52%) reported nonvisual aura symptoms as part of their migraine attack. The most prevalent nonvisual aura symptoms were somatosensory, followed by language problems (Figure 2(b)). A significant percentage (19%) of
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(CEP)
[1–9] [PREPRINTER stage]
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Jakob et al.
276 screened 9 screening failures
Patient reported data
267 patients provided attack data 66 dropped out
Phase I
201 patients reporting 456 attacks of migraine with aura
37 did not treat migraine with aura 29 protocol deviation g failures
37 dropped out
Phase II
164 patients reporting 405 attacks of migraine with aura
37 did not treat migraine with aura
Figure 1. Trial profile. Table 1. Demographics and headache characteristics at inclusion.
Enrollment Age at inclusion (years) Age of migraine onset (years) Age of migraine diagnose (years) Interval from migraine onset to diagnoses (years) Migraine attacks per month Attack duration (hours, range) >50% of attacks preceded by aura Acute antimigraine treatment Migraine prophylaxis
All patients
Women
Men
267 (100%) 38.9 (11.3) 17.8 (9.3) 24.0 (4–58.4) 6.2 (0–40.1) 4.2 (2.1) 21.9 (1–168) 70.4% 259 (97%) 107 (40%)
215 (80.5%) 39.1 (11.2) 17.9 (9.5) 24.3 (4–58.4) 6.5 (0–40.1) 4.3 (2.1) 23.5 (1–168) 70.3% 208 (96.7%) 90 (41.8%)
52 (19.5%) 38.4 (11.6) 17.4 (8.6) 22.4 (5–47.3) 5 (0–29.5) 4.1 (2.2) 15.3 (2–72) 70.7% 51 (98%) 17 (32.7%)
Data are number of patients (%) or mean (SD or range), women vs. men (p ¼ NS) for all variables except attack duration (p ¼ 0.005).
patients reported a change in olfaction. Many patients reported more than one nonvisual aura symptom (median 1, range 1–4). Few patients (n ¼ 47) reported just one aura symptom, and then only visual symptoms: the most prevalent being dots or flashing lights (n ¼ 22), or other visual symptoms, including halos and blurry vision, kaleidoscopic images and micropsia (n ¼ 12) and wavy or jagged lines (n ¼ 9).
used more than one drug: acute treatment (1.7 1.0), preventives (1.6 0.99). Patients were allowed to continue on preventive therapy during the prospective phase. Preventive medication was being taken by 76 patients (38%) accounting for 43% of attacks in phase I and 63 patients (38%) in phase II, accounting for 37% of attacks in phase II. The use of analgesics, antiemetics, triptans, ergots, or other drugs that could confound trial assessment were allowed within the 12-hour period before treatment.
Treatment Of the 267 patients, 259 (97%) reported using acute therapy medication, whereas 107 (40%) were actively taking preventive therapy. The majority of patients
Migraine attack characteristics Most of the prospectively recorded migraine attacks with aura occurred during the wake hours, in a bimodal
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4
Cephalalgia 0(0)
45 40
Numbers of attacks
35 30 25 20 15 10 5
8- 9 9- 1 0 10 - 11 11 - 12 12 - 13 13 - 14 14 - 15 15 - 16 16 - 17 17 - 18 18 - 19 19 - 20 20 - 21 21 - 22 22 - 23 23 - 00
6- 7 7- 8
4- 5 5- 6
2- 3 3- 4
01 1- 2
0
Time
Figure 2. Recorded time of attack onset, recorded during phase I (N ¼ 456 in 201 patients).
(a)
Dots or Flashing Lights
Wavy or Jagged Lines (n=125, 47 %)
18
50
(6%)
(19%)
(4%)
10
32
27
8
(10%)
(3%)
(4%)
(n=69, 26 %)
27
32
(10%)
9 (3%)
6
8
(2%)
(3%)
(n=113, 42 %)
6
4
10 5
6
(2%)
(2%)
4 9
(3%)
6 (2%)
(1.5%)
30 (11%)
(n=79, 29.5 %)
(12%)
5 (2%)
(6%)
Blind Spots
13 (5%)
15 (6%)
16
Numbness or Pins and Needles
Recalling or Speaking
(n=188, 70 %)
(12%)
11
(b)
(1.5%)
(2%)
(3%)
Tunnel Vision (n=73, 27 %)
Changes in Smell (n=50, 19 %)
8
0
(3%)
(0%)
5
5 (2%)
6 (2%)
(2%)
Changes in Taste or Touch (n=38, 14 %)
Figure 3. (a) Venn diagram showing the prevalence and combinations of the four most reported visual aura symptoms (N ¼ 251). (b) Venn diagram showing the prevalence and combinations of the four most reported non-visual aura symptoms (N ¼ 140). Aura symptoms in self-reported attacks; number of patients and % of all patients (N ¼ 267).
pattern, with peaks before noon and in the early evening hours (Figure 3). There was a higher incidence and severity of migraine symptoms (pain, nausea, photophobia and phonophobia) in the retrospective reporting of migraine attack characteristics compared with prospectively collected data (p < 0.01 for all, see Table 2). Most retrospectively reported migraine attacks were frequently or always associated with photophobia
(98.1%) and phonophobia (86.9%), while the corresponding figure for nausea was 73.1%. In the prospectively recorded attacks, 421 attacks (49%) were not associated with nausea (Table 2), and in only 135 attacks (16%) was the nausea rated as moderate or severe. Retrospective reporting indicated that although 157 (59%) patients vomited during some attacks, a large minority of 110 patients (41%) never vomited, and 105 (39%) vomited in less than 25% of attacks,
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Jakob et al. whereas 52 patients (20%) vomited in more than 25% of attacks. In prospective reporting, 10 patients reported vomiting in 13 attacks (3%). The retrospective reporting of moderate/severe nausea decreased with increasing patient age (a 23% reduction between age groups 18–30 and 51–68 years) and the same was true for prospectively recorded attacks (a 41% reduction between age groups 18–30 and 51–68 years) (Figure 4).
Table 2. Migraine symptoms prevalence (% of attacks, number) self-reported and in the prospective recordings.
Headache Nausea Photophobia Phonophobia
Self-reported (N ¼ 267 patients)
Prospective (N ¼ 861 attacks)
100% (267) 95.8% (256) 100% (267) 97.8% (261)
73% (628) 51% (439) 88% (759) 73% (632)
p value
(CEP)
[1–9] [PREPRINTER stage]
Original Article
Variability of clinical features in attacks of migraine with aura
Cephalalgia 0(0) 1–9 ! International Headache Society 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0333102415584601 cep.sagepub.com
Jakob M Hansen1, Peter J Goadsby2 and Andrew C Charles1 Abstract Background: There is significant variability in the clinical presentation of migraine, both among patients, and between attacks in an individual patient. We examined clinical features of migraine with aura in a large group of patients enrolled in a clinical trial, and compared retrospective migraine attack characteristics reported upon enrollment in the trial with those recorded prospectively in the trial. Methods: Patients with migraine (n ¼ 267) with typical visual aura in more than 30% of their attacks were enrolled from 16 centers for a clinical trial. Upon enrollment, patients provided a detailed retrospective description of the clinical features of their attacks of migraine. During the trial, clinical symptoms in migraine attacks starting with aura were recorded prospectively in 861 attacks. Results: Retrospectively reported visual aura symptoms were variable and often overlapping; the most common symptoms were dots or flashing lights, wavy or jagged lines, blind spots, and tunnel vision. Multiple patients reported more than one visual phenomenon. Approximately half of the patients reported nonvisual aura symptoms, the most common were numbness and tingling, followed by difficulty in recalling or speaking words. A significant percentage of patients also reported a change in olfaction. There were several inconsistencies between the features of prospectively recorded and retrospectively reported attacks. Headache, nausea, photophobia, and phonophobia were all less common in prospectively recorded attacks as compared with retrospective reporting. Nausea was prospectively recorded in only 51% of attacks and mostly with mild intensity. The occurrence and severity of nausea was reduced with advancing patient age. Phonophobia was not consistently recorded in conjunction with photophobia. Conclusion: These findings are consistent with variable involvement of different brain regions during a migraine attack. The variable occurrence of nausea, and phonophobia in conjunction with photophobia, both defining features of migraine, may be an important consideration in designing clinical studies of migraine in which prospectively recorded attacks are diagnosed based on these clinical features. Keywords Migraine aura, clinical characteristics, RCT, prospective recordings, cohort study, cortical spreading depression Date received: 9 February 2015; revised: 4 March 2015; 15 March 2015; accepted: 19 March 2015
Introduction Migraine is the most disabling (1) and prevalent neurological disorder with more than 80 million sufferers in Europe and the United States (US) alone (2). The clinical presentation of attacks of migraine varies considerably, both among patients and within each patient. While this variability is obvious in routine clinical practice it has not been extensively characterized prospectively, particularly for migraine with aura. Most reports of the clinical characteristics of migraine with aura are retrospective (3–9), and the available prospective studies (10–12) are based on a limited number of patients. This study uses data from a large prospective randomized clinical trial (13) to analyze the characteristics of migraine aura and other symptoms in migraine attacks
in a large cohort of patients with migraine with aura. We have previously reported based on this data that clinical features of migraine—headache, nausea, 1 Headache Research and Treatment Program, Department of Neurology, University of California Los Angeles, USA 2 Headache Group, Clinical Neurosciences and NIHR-Wellcome Trust Clinical Research Facility, King’s College London, UK
Corresponding author: Jakob M Hansen, MD, PhD, Danish Headache Center and Department of Neurology, Rigshospitalet, Glostrup, Faculty of Health Sciences, University of Copenhagen, Nordre Ringvej 57, DK-2600 Glostrup, Copenhagen, Denmark. Email: [email protected]
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(CEP)
[1–9] [PREPRINTER stage]
2 photophobia, and phonophobia—are commonly present during the aura phase of an attack (14). The diagnosis of migraine is based on patient reporting of attack features. However, some clinical studies of migraine, particularly clinical trials of preventive therapies, involve prospective documentation of migraine attacks. In these studies, variation of attack characteristics may represent a significant confounding factor. The goal of this study was two-fold: first, to describe the clinical features of migraine with typical aura in a large group of patients enrolled in a clinical trial, and secondly, to compare self-reported (retrospective) migraine symptoms to prospective recordings of attacks in the same patients.
Methods Patients aged 18–70 years and meeting International Classification of Headache Disorders, second edition (ICHD-II) criteria for migraine with typical visual aura (15) were recruited from 16 centers in the US for a double-blind, placebo-controlled trial of the therapeutic efficacy of single-pulse transcranial magnetic stimulation (sTMS) for attacks of migraine with aura (13). Patients were eligible for inclusion if they had a consistent history of migraine with visual aura of at least one year, one to eight migraine episodes per month and visual aura preceding the migraine for at least 30% of episodes, followed by moderate or severe headache in 90% of attacks. Key exclusion criteria were aura lasting for more than 60 minutes, presence of metal implants, headaches due to underlying pathology or trauma, and overuse of drugs for headaches or use of drugs that could confound interpretation of study results. Data from individual patients were summarized using frequency counts with percentages and descriptive statistics such as means and standard deviation. Statistical analyses were performed with SPSS 17.0 (Chicago, IL) for Windows. Five percent (p ¼ 0.05) was chosen as the level of significance.
Patient-delivered symptoms report Retrospective attack characteristics were collected on inclusion. Prospective data was recorded by patients in an electronic diary as soon as possible after aura began and always within one hour of aura onset. All prospective data in this analysis were collected before any treatment. Patients were asked to rate the most prevalent symptoms: headache, nausea, photophobia and phonophobia, on a four-point scale; 0 no symptoms; 1 mild; 2 moderate; and 3 severe. Less common symptoms and visual and nonvisual aura symptoms were dichotomized to yes/no responses.
Cephalalgia 0(0)
Standard protocol approvals, registrations, and patient consents All study centers provided institutional review board approval before study initiation, and all participants gave written informed consent. The trial was registered with ClinicalTrials.gov, number NCT00449540.
Results A total of 276 patients with migraine with aura were screened, and 267 enrolled in the study and provided the historical clinical attack data. The prospective part of the study consisted of a run-in phase (phase I) where 201 patients reported 456 attacks, and a treatment phase (phase II) where 164 patients were treated either with sTMS or sham stimulation and reported 405 attacks. In total, we report data from 861 prospectively recorded migraine attacks with aura (Figure 1). The majority of patients were female (81%) and Caucasian (87%). The mean age of onset was 17.8 years, mean duration of disease was 21.2 years with a diagnostic delay (time from migraine onset to diagnosis) of 6.2 years. There were no significant gender differences for the important demographic characteristics, except for attack duration (Table 1). Patient reports on the relation between menstruation and migraine were available from 151 women; a large minority (40%) reported that migraine attacks were related to the menstrual cycle, with attacks occurring within 2 to þ3 days of menstruation.
Aura symptoms Detailed reports of aura symptoms are based on retrospective patient reports (n ¼ 267). The aura symptoms for women and men did not differ, and pooled data are presented. As per the inclusion criteria, all 267 patients reported visual symptoms as part of their migraine aura. Most patients reported more than one visual aura symptom, (median 2, range 1–5). The most prevalent visual aura symptoms were dots or flashing lights, wavy or jagged lines and scotoma. Figure 2(a) demonstrates an overview of the different combinations of the most prevalent visual aura symptoms. Additional visual symptoms classified as aura included hallucinations (n ¼ 22), blurry vision (n ¼ 22), photopsia (n ¼ 14), halos (n ¼ 7), obscuration (n ¼ 4) and micropsia (n ¼ 1). Approximately half of the patients (52%) reported nonvisual aura symptoms as part of their migraine attack. The most prevalent nonvisual aura symptoms were somatosensory, followed by language problems (Figure 2(b)). A significant percentage (19%) of
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(CEP)
[1–9] [PREPRINTER stage]
3
Jakob et al.
276 screened 9 screening failures
Patient reported data
267 patients provided attack data 66 dropped out
Phase I
201 patients reporting 456 attacks of migraine with aura
37 did not treat migraine with aura 29 protocol deviation g failures
37 dropped out
Phase II
164 patients reporting 405 attacks of migraine with aura
37 did not treat migraine with aura
Figure 1. Trial profile. Table 1. Demographics and headache characteristics at inclusion.
Enrollment Age at inclusion (years) Age of migraine onset (years) Age of migraine diagnose (years) Interval from migraine onset to diagnoses (years) Migraine attacks per month Attack duration (hours, range) >50% of attacks preceded by aura Acute antimigraine treatment Migraine prophylaxis
All patients
Women
Men
267 (100%) 38.9 (11.3) 17.8 (9.3) 24.0 (4–58.4) 6.2 (0–40.1) 4.2 (2.1) 21.9 (1–168) 70.4% 259 (97%) 107 (40%)
215 (80.5%) 39.1 (11.2) 17.9 (9.5) 24.3 (4–58.4) 6.5 (0–40.1) 4.3 (2.1) 23.5 (1–168) 70.3% 208 (96.7%) 90 (41.8%)
52 (19.5%) 38.4 (11.6) 17.4 (8.6) 22.4 (5–47.3) 5 (0–29.5) 4.1 (2.2) 15.3 (2–72) 70.7% 51 (98%) 17 (32.7%)
Data are number of patients (%) or mean (SD or range), women vs. men (p ¼ NS) for all variables except attack duration (p ¼ 0.005).
patients reported a change in olfaction. Many patients reported more than one nonvisual aura symptom (median 1, range 1–4). Few patients (n ¼ 47) reported just one aura symptom, and then only visual symptoms: the most prevalent being dots or flashing lights (n ¼ 22), or other visual symptoms, including halos and blurry vision, kaleidoscopic images and micropsia (n ¼ 12) and wavy or jagged lines (n ¼ 9).
used more than one drug: acute treatment (1.7 1.0), preventives (1.6 0.99). Patients were allowed to continue on preventive therapy during the prospective phase. Preventive medication was being taken by 76 patients (38%) accounting for 43% of attacks in phase I and 63 patients (38%) in phase II, accounting for 37% of attacks in phase II. The use of analgesics, antiemetics, triptans, ergots, or other drugs that could confound trial assessment were allowed within the 12-hour period before treatment.
Treatment Of the 267 patients, 259 (97%) reported using acute therapy medication, whereas 107 (40%) were actively taking preventive therapy. The majority of patients
Migraine attack characteristics Most of the prospectively recorded migraine attacks with aura occurred during the wake hours, in a bimodal
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4
Cephalalgia 0(0)
45 40
Numbers of attacks
35 30 25 20 15 10 5
8- 9 9- 1 0 10 - 11 11 - 12 12 - 13 13 - 14 14 - 15 15 - 16 16 - 17 17 - 18 18 - 19 19 - 20 20 - 21 21 - 22 22 - 23 23 - 00
6- 7 7- 8
4- 5 5- 6
2- 3 3- 4
01 1- 2
0
Time
Figure 2. Recorded time of attack onset, recorded during phase I (N ¼ 456 in 201 patients).
(a)
Dots or Flashing Lights
Wavy or Jagged Lines (n=125, 47 %)
18
50
(6%)
(19%)
(4%)
10
32
27
8
(10%)
(3%)
(4%)
(n=69, 26 %)
27
32
(10%)
9 (3%)
6
8
(2%)
(3%)
(n=113, 42 %)
6
4
10 5
6
(2%)
(2%)
4 9
(3%)
6 (2%)
(1.5%)
30 (11%)
(n=79, 29.5 %)
(12%)
5 (2%)
(6%)
Blind Spots
13 (5%)
15 (6%)
16
Numbness or Pins and Needles
Recalling or Speaking
(n=188, 70 %)
(12%)
11
(b)
(1.5%)
(2%)
(3%)
Tunnel Vision (n=73, 27 %)
Changes in Smell (n=50, 19 %)
8
0
(3%)
(0%)
5
5 (2%)
6 (2%)
(2%)
Changes in Taste or Touch (n=38, 14 %)
Figure 3. (a) Venn diagram showing the prevalence and combinations of the four most reported visual aura symptoms (N ¼ 251). (b) Venn diagram showing the prevalence and combinations of the four most reported non-visual aura symptoms (N ¼ 140). Aura symptoms in self-reported attacks; number of patients and % of all patients (N ¼ 267).
pattern, with peaks before noon and in the early evening hours (Figure 3). There was a higher incidence and severity of migraine symptoms (pain, nausea, photophobia and phonophobia) in the retrospective reporting of migraine attack characteristics compared with prospectively collected data (p < 0.01 for all, see Table 2). Most retrospectively reported migraine attacks were frequently or always associated with photophobia
(98.1%) and phonophobia (86.9%), while the corresponding figure for nausea was 73.1%. In the prospectively recorded attacks, 421 attacks (49%) were not associated with nausea (Table 2), and in only 135 attacks (16%) was the nausea rated as moderate or severe. Retrospective reporting indicated that although 157 (59%) patients vomited during some attacks, a large minority of 110 patients (41%) never vomited, and 105 (39%) vomited in less than 25% of attacks,
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Jakob et al. whereas 52 patients (20%) vomited in more than 25% of attacks. In prospective reporting, 10 patients reported vomiting in 13 attacks (3%). The retrospective reporting of moderate/severe nausea decreased with increasing patient age (a 23% reduction between age groups 18–30 and 51–68 years) and the same was true for prospectively recorded attacks (a 41% reduction between age groups 18–30 and 51–68 years) (Figure 4).
Table 2. Migraine symptoms prevalence (% of attacks, number) self-reported and in the prospective recordings.
Headache Nausea Photophobia Phonophobia
Self-reported (N ¼ 267 patients)
Prospective (N ¼ 861 attacks)
100% (267) 95.8% (256) 100% (267) 97.8% (261)
73% (628) 51% (439) 88% (759) 73% (632)
p value
