In her essay “In Bed,” writer Joan Didion describes migraine as a “complex of symptoms, the most frequently noted but by no means the most unpleasant of which is a vascular headache of blinding severity. . . . ”
For a minority of those with migraine, that complex of unpleasant symptoms doesn’t even include a headache, though the symptoms that do remain can be unpleasant in the extreme. “Headache is not synonymous with migraine, but it is one of the cardinal features,” explains Robert Pearlman, MD, associate clinical professor of neurology at the University of Alabama at Birmingham School of Medicine.
That makes diagnosing migraine without headache very challenging.
Out of phase
A typical migraine is often preceded by a phase, the aura, that may include a cluster of symptoms such as visual disturbances, neck pain, dizziness, sensitivity to light, sound, and odors, confused thinking, and difficulty speaking. This is typically followed by not only headache, but often extreme light sensitivity, nausea, and even vomiting. In a small group of patients, and particularly the elderly, the headache is absent. The condition was once referred to as “acephalgic migraine” and is still sometimes referred to as “silent migraine.”
The modern classification, found in the The International Classification of Headache Disorders 3rd edition, is "typical aura without headache,” though a more accurate and useful term is simply, migraine without headache, says Stephen Silberstein, MD, Director of the Headache Center at Thomas Jefferson University in Philadelphia, and member of the American Neurological Association.
Not surprisingly, migraine with no headache can pose a conundrum for physicians. “The only way to diagnose this as migrainous is to rule out everything else,” says Pearlman. “It’s a diagnosis of exclusion; you don’t want to diagnose migraine first.”
Next: Migraine or TIA?