Don’t Miss it: Basilar Migraine

Abstract

Basilar migraine is a type of migraine which is characterized by headache with other features such as dizziness, ataxia, tinnitus, decreased hearing, nausea and vomiting, dysarthria, diplopia, loss of balance, bilateral paresthesias or paresis, altered consciousness, syncope and sometimes loss of consciousness. It is most commonly seen in young females. Localized transient vasoconstriction in the posterior circulation is currently thought to be the cause of this entity. Patient should be aware of the risk factors as well as the management strategy of this disorder. We have mentioned a case of a 33 year old female with three episodes of transient unconsciousness. It is very important to correctly diagnose this on the basis of history and differentiate it from seizures and syncope.

Keywords: Basilar migraine; Bickerstaff syndrome; Unconsciousness

Case Presentation

A 33 year old female presented in with history of three episodes of transient unconsciousness in one month. She described about having mild bi-temporal throbbing headache with uneasiness for a period of few minutes which was always associated with diaphoresis and diminution of vision. Each time, this was followed by vertiginous feeling and unconsciousness. All the episodes of unconsciousness lasted for around a minute and were not followed by any confusion. There was no tonic or tonic-clonic activity of the limbs. There was no family history of similar events or headache. She was evaluated for these episodes. The routine hematological tests were normal. She was then subjected to video EEG in which, one clinical event of similar semiology as described by the patient was recorded but it did not show any epileptiform discharges. Considering these as episodes of basilar migraine, she was started on divalproex sodium as prophylaxis (with NSAID for anticipated acute event) and following which, she did not have any similar episodes since one year.

Discussion

Basilar migraine (BM), also known as Bickerstaff syndrome consists of headache accompanied by dizziness, ataxia, tinnitus, decreased hearing, nausea and vomiting, dysarthria, diplopia, loss of balance, bilateral paresthesias or paresis, altered consciousness, syncope and sometimes loss of consciousness [1]. BM is observed most frequently in adolescent girls and young women. Localized vertebrobasilar vasoconstriction leading to transient posterior circulation ischemia is said to contribute to the symptomatology of the disorder. The ICHD-III-beta criteria define that migraine aura should include at least two of the following symptoms: dysarthria, vertigo, tinnitus, hypacusia, diplopia, ataxia, and decreased level of consciousness. In addition, most patients have typical visual, sensory, or aphasic aura during attacks of migraine with brainstem aura as do patients with typical aura [2]. Some authors are skeptical about the fact that this entity is an independent entity from migraine with typical aura. A recent study conducted by Kirchmann and colleagues on patients with migraine with aura found that brainstem aura occurred in 10 % (38/362) of patients with migraine with typical aura. The authors concluded that brainstem aura seemingly may occur at time in any patient with migraine with typical aura and that there is no firm clinical, epidemiologic, or genetic evidence that basilar-type migraine is an independent disease entity different from migraine with typical aura [3]. Management includes prevention of risk and precipitating factors with treatment with drugs for pain relief including NSAIDs as well as drugs such as topiramate or valproate for prophylaxis.

Conclusion

Basilar-type migraine is an episodic disorder and occurs in around 1.5% of patients with headache. More than one-half of these patients have their first attack in the second and third decade of life. Trigger factors are common, and patients should be educated to avoid trigger factors.

References

1. Evans RW, Linder SL. Management of basilar migraine. Headache. 2002; 42: 383-384.
2. Headache Classification Committee of the International Headache. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33: 629-808.
3. Kirchmann M, Thomsen LL, Olesen J. Basilar-type migraine: clinical, epidemiologic, and genetic features. Neurology. 2006; 66: 880-886.