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Suggest Treatment For Migraine With Aura
Question: I have CADASIL. Diagnosed 2007 by genetic testing. Female 58. Many with it in my family. OHSU was the first health care provider to actually witness episode of what they called migraine. I have MRI's back to 2000 showing WMD and stroke. I have had many TIA's. Can clinical episode visual assessment only distinguish between mere migraine with aura, TIA and micro-bleed strokes/lacunar syndrome?
Brief Answer:
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Detailed Answer:
Hello and welcome back to HealthcareMagic.
Migraine with aura can usually be clinically diagnosed when it is of a typical presentation. The association of aura with following headache is not typical for TIAs, microbleeds or lacunes, they aren't usually associated with headache. So if the episode fulfills the criteria for migraine with aura routine then imaging is not required, it may be only clinically diagnosed.
Meanwhile distinguishing between TIAs and microbleeds or lacunar stroke is not always that easy. Actually in many patients with transitory symptoms it has been shown by studies to be some type of lesion present. That is why in recent years the definition of a TIA has changed. It is not only clinical anymore. By current definition there has to be a transitory deficit with normal imaging. So clinical assessment alone is not considered enough.
I remain at your disposal for other questions.
Read below.
Detailed Answer:
Hello and welcome back to HealthcareMagic.
Migraine with aura can usually be clinically diagnosed when it is of a typical presentation. The association of aura with following headache is not typical for TIAs, microbleeds or lacunes, they aren't usually associated with headache. So if the episode fulfills the criteria for migraine with aura routine then imaging is not required, it may be only clinically diagnosed.
Meanwhile distinguishing between TIAs and microbleeds or lacunar stroke is not always that easy. Actually in many patients with transitory symptoms it has been shown by studies to be some type of lesion present. That is why in recent years the definition of a TIA has changed. It is not only clinical anymore. By current definition there has to be a transitory deficit with normal imaging. So clinical assessment alone is not considered enough.
I remain at your disposal for other questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Having absolute proof of CADASIL (extremely age-related condition symptomatically) with people my age often suffering hemmorahgic strokes, inability to walk unassisted and more; and, having had multiple MRI's (in 2016 showing moderate to severe increase in lesions) would it not - with those two factors alone - make Migraine a wrong diagnosis? "Sub-cortical infarct" in the disease name can be downplayed to a Migraine diagnosis due to no medical evidence when it is known the genetic condition is relentlessly progressive? My episodes are acute at first and then trail lesser for several days after each time. I have had 11 micro bleed episodes since 9-9-16. Can't have MRI's every time. Isn't the implication that Migraines are a lesser symptom, and so possibly not the correct diagnosis at all? By the way, I am well aware that my condition has no treatment or cure and I have MRI's for knowledge of progression for life planning and choices. I do not see a clear explanation from you about the symptom names. Please be more clear? Compare Migraine w/Aura, Lacunar Syndrome/Lacunes, TIA, Sub-Cortical Infarcts, Stroke, Multiple Micro-bleed Ischemic Strokes. I need a more substantive answer, please.
Brief Answer:
Read below
Detailed Answer:
Hello again. Sorry for answering a little late but your question had come at night (time differences) and I could find the time to answer at work only now.
Migraine with aura is part of the clinical manifestations of Cadasil. It is usually the most early manifestation. It often comes before the stroke episodes, it is not related to a new stroke, in the early stages there may be migraine without anything on MRI at all. So it is different from the stroke episodes (whether TIA, subcortical infarcts or microhemorrhages). They may coexist together but in the early stages there may be migraine alone, with infarcts and at times microhemorrhages following later on (microhemorrhages are not in all patients and usually in later stages).
So having subcortical infarcts or microhemorrhages doesn’t mean that the migraine with aura episodes are incorrectly called so. Actually a microhemorrhage or subcortical infarction doesn’t usually cause any headache in itself. So having recurrent episodes of aura (usually visual) followed by migrainous headache is enough to make the migraine with aura diagnosis.
A TIA is a neurological deficit (may take many forms depending on the blood vessel involved – usually speech issues weakness or numbness of limbs on one side) which is transitory, passes inside an hour usually and shows no new lesions on MRI.
A lacunar stroke is a small stroke, infarct, less than 1.5 cm, due to blockage of a small blood vessel. Symptoms may vary depending on where it happens, it is common not to have any symptom at all found only in imaging, when there are symptoms usually again in the form of weakness or numbness on one side.
Subcortical infarct is again a stroke, but bigger then a lacune. Usually lacunes are more deep in the brain while as the name suggests subcortical infarcts are more close to the surface, under the cortex. Again symptoms may vary according to location, may have no symptom at all and found only in imaging.
Lastly microhemorrhages are rupture of a small vessel causing a small bleed. Usually cause no symptoms and are noticed incidentally on MRI. Are not necessarily found in CADASIL, only in 25-50% of patients.
So as you can see migraine is the only event necessarily involving headache. The other events may cause mild deficits like weakness or numbness on the one side or no symptoms at all and be found occasionally on imaging, it is the MRI which differentiates them from each other, not symptoms alone. That is because in isolation the damage a single event causes, the lost brain tissue, is small, but over the decades these brain matter losses accumulate on top of each other adding up and leading to dementia.
I hope this was what you wanted to know.
Read below
Detailed Answer:
Hello again. Sorry for answering a little late but your question had come at night (time differences) and I could find the time to answer at work only now.
Migraine with aura is part of the clinical manifestations of Cadasil. It is usually the most early manifestation. It often comes before the stroke episodes, it is not related to a new stroke, in the early stages there may be migraine without anything on MRI at all. So it is different from the stroke episodes (whether TIA, subcortical infarcts or microhemorrhages). They may coexist together but in the early stages there may be migraine alone, with infarcts and at times microhemorrhages following later on (microhemorrhages are not in all patients and usually in later stages).
So having subcortical infarcts or microhemorrhages doesn’t mean that the migraine with aura episodes are incorrectly called so. Actually a microhemorrhage or subcortical infarction doesn’t usually cause any headache in itself. So having recurrent episodes of aura (usually visual) followed by migrainous headache is enough to make the migraine with aura diagnosis.
A TIA is a neurological deficit (may take many forms depending on the blood vessel involved – usually speech issues weakness or numbness of limbs on one side) which is transitory, passes inside an hour usually and shows no new lesions on MRI.
A lacunar stroke is a small stroke, infarct, less than 1.5 cm, due to blockage of a small blood vessel. Symptoms may vary depending on where it happens, it is common not to have any symptom at all found only in imaging, when there are symptoms usually again in the form of weakness or numbness on one side.
Subcortical infarct is again a stroke, but bigger then a lacune. Usually lacunes are more deep in the brain while as the name suggests subcortical infarcts are more close to the surface, under the cortex. Again symptoms may vary according to location, may have no symptom at all and found only in imaging.
Lastly microhemorrhages are rupture of a small vessel causing a small bleed. Usually cause no symptoms and are noticed incidentally on MRI. Are not necessarily found in CADASIL, only in 25-50% of patients.
So as you can see migraine is the only event necessarily involving headache. The other events may cause mild deficits like weakness or numbness on the one side or no symptoms at all and be found occasionally on imaging, it is the MRI which differentiates them from each other, not symptoms alone. That is because in isolation the damage a single event causes, the lost brain tissue, is small, but over the decades these brain matter losses accumulate on top of each other adding up and leading to dementia.
I hope this was what you wanted to know.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Based on my knowledge of my disease, all migraine with aura would cause permanent harm because they leave lesions, which proves they are not mere migraines. What you are saying cannot be accurate because I have increasing brain damage proven by symptoms and MRI, and therefore my symptoms cannot be mere migraine with aura or even mere TIA leaving no damage. The fact that I suffer for days after a bleed indicates much more is going in including inflammation and true actual bleeds. The fact that my MRi's from 2000, 2006 and 2016 show moderate to advanced ischemic disease means that these are not mere migraines, or mere TIA's. I hope you comprehend the issue. Are you aware that CADASIL is progressive and that SOMETHING (including stroke) is causing these MRI findings? Therefore, your answer still does not suffice. Sime doctors call CADASIL "leaky hose syndome" for the arteriopathic systemic nature of this genetic disease which resembles Multiple Scleroses. Therefore, my original question still stands unanswered. How does a doctor assign a diagnosis of Migraine with Aura in an older person with known progressive CADASIL by visual exam alone, verified by MRI and ganetic testing -- rather than diagnosing TIA, micro-bleed stroke, Lacunes/Lacunar Syndrome? Do you have any experience with CADASIL? I need to know these differences, which is my question.
Brief Answer:
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Detailed Answer:
It seems to me that you misunderstood me. I never said that you have only migraine and no brain damage, please read again my last answer. Of course that you have brain damage as shown by MRI, otherwise you wouldn’t have a diagnosis of CADASIL, it is not the migraine headache with aura alone which makes the diagnosis, it is the combination of migraine, brain vascular damage and family history which does (confirmed by genetic tests).
It seemed to me that what you were implying was that you had been misdiagnosed with migraine when instead you had damage in the form of infarcts and microhemorrhages. Correct me if I was wrong. So what I was trying to explain (it seems not eloquently enough) is that in CADASIL there could be migraine AND brain damage, that having brain damage does not mean that the doctors were wrong in calling them migraine with aura.
Not all migraine with aura patients have brain damage, that statement is not correct, there is a higher risk for stroke than non-migrainous patients but a higher risk does not mean all of them. There may be some changes of the brain matter but not the strokes found in CADASIL, not associated with dementia.
I am a neurologist who works in a Stroke Unit as a regular job, so of course I have dealt with CADASIL patients. In all of them there has been a history of migrainous headache associated with stroke and diffuse white matter changes on MRI and later on mainly in the 6th decade of their life with dementia. The presence of migraine headaches is a feature in most CADASIL patients, present in every description of the condition. Of course such patients are not the same with common migraine, but the clinical presentation is the same.
If what you mean is how am I able to differentiate whether there is an episode of migraine aura or a new stroke it is by the fact that the aura is reversible in less than an hour and headache ensues, in an infarct or microhemorrhage when there is a neurological deficit it lasts longer. If I say to the patient that I think at that moment in time he has a migraine with aura that doesn’t mean that I am saying that there is no vascular damage to the brain, as you say yourself it is a chronic progressive disease where more and more damage is added over time.
Whether judging that way by the description of the symptoms alone is infallible, of course not, it may happen that brain MRI may show it to be a new lesion. But we can’t have MRIs for every migrainous episode, there are patients which have headaches every week. We think there is a high suspicion of an episode not being simply migraine with aura and ask for a MRI when there are symptoms like weakness, numbness etc which last for more than an hour. In that case an infarct or microhemorrhage is suspected (but only the MRI can confirm it, not visual inspection).
I hope to have been more understandable this time around. Let me know if I can further assist you.
Read below
Detailed Answer:
It seems to me that you misunderstood me. I never said that you have only migraine and no brain damage, please read again my last answer. Of course that you have brain damage as shown by MRI, otherwise you wouldn’t have a diagnosis of CADASIL, it is not the migraine headache with aura alone which makes the diagnosis, it is the combination of migraine, brain vascular damage and family history which does (confirmed by genetic tests).
It seemed to me that what you were implying was that you had been misdiagnosed with migraine when instead you had damage in the form of infarcts and microhemorrhages. Correct me if I was wrong. So what I was trying to explain (it seems not eloquently enough) is that in CADASIL there could be migraine AND brain damage, that having brain damage does not mean that the doctors were wrong in calling them migraine with aura.
Not all migraine with aura patients have brain damage, that statement is not correct, there is a higher risk for stroke than non-migrainous patients but a higher risk does not mean all of them. There may be some changes of the brain matter but not the strokes found in CADASIL, not associated with dementia.
I am a neurologist who works in a Stroke Unit as a regular job, so of course I have dealt with CADASIL patients. In all of them there has been a history of migrainous headache associated with stroke and diffuse white matter changes on MRI and later on mainly in the 6th decade of their life with dementia. The presence of migraine headaches is a feature in most CADASIL patients, present in every description of the condition. Of course such patients are not the same with common migraine, but the clinical presentation is the same.
If what you mean is how am I able to differentiate whether there is an episode of migraine aura or a new stroke it is by the fact that the aura is reversible in less than an hour and headache ensues, in an infarct or microhemorrhage when there is a neurological deficit it lasts longer. If I say to the patient that I think at that moment in time he has a migraine with aura that doesn’t mean that I am saying that there is no vascular damage to the brain, as you say yourself it is a chronic progressive disease where more and more damage is added over time.
Whether judging that way by the description of the symptoms alone is infallible, of course not, it may happen that brain MRI may show it to be a new lesion. But we can’t have MRIs for every migrainous episode, there are patients which have headaches every week. We think there is a high suspicion of an episode not being simply migraine with aura and ask for a MRI when there are symptoms like weakness, numbness etc which last for more than an hour. In that case an infarct or microhemorrhage is suspected (but only the MRI can confirm it, not visual inspection).
I hope to have been more understandable this time around. Let me know if I can further assist you.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
No. You won't explain how a doctor can differentiate between the conditions by visual evidence alone nor address how my episodes last up to 4 days with symptoms of inflammation, following all stroke symptoms. Lacunar Syndrome, sub-cortical infarcts, micro-bleeds... these are different terms for a reason. You won't explain how you make diagnosis differentiating between the diagnoses, but that is what I am requesting.
Brief Answer:
Read below
Detailed Answer:
I suppose by visual evidence you mean history and clinical exam, without the aid of imaging.
By that way a doctor can't differentiate between all those things. He can differentiate by the duration of symptoms and the headache on whether there is a new lesion or a migrainous aura. But one can't differentiate with certainty between a lacunar infarct, a subcortical infarct or a microbleed, not with clinical exam alone. You are correct in saying they are different terms for a reason, but the difference is made through MRI. As I said on MRI the lacunes are infarctions which are small in size (usually defined as <20 mm), due to obstruction of the small deep penetrating arteries. Symptoms depend on location, at times may be silent.
Subcortical infarcts are again infarcts, but involve different arteries located mainly in the subcortical white matter.
Microbleeds are not infarcts, not obstruction of an artery, they are bleeds due to rupture of an artery.
For all of these lesions the symptoms may be similar, like weakness of the limbs, numbness or loss of sensation, speech articulation difficulties, coordination issues etc depend on the location of the lesion. At times the patient may even not notice any symptom at that moment but still there is damage which contributes to the dementia which is seen in later stages. The distinction of the lesions is done by MRI, not visual evidence, visual evidence is used only to try and filter which cases are due to migrainous aura so that MRI is not ordered uselessly. If symptoms last for 4 days as you say then they shouldn't be due to aura but due to a lesion and I would order a MRI to differentiate which one.
Read below
Detailed Answer:
I suppose by visual evidence you mean history and clinical exam, without the aid of imaging.
By that way a doctor can't differentiate between all those things. He can differentiate by the duration of symptoms and the headache on whether there is a new lesion or a migrainous aura. But one can't differentiate with certainty between a lacunar infarct, a subcortical infarct or a microbleed, not with clinical exam alone. You are correct in saying they are different terms for a reason, but the difference is made through MRI. As I said on MRI the lacunes are infarctions which are small in size (usually defined as <20 mm), due to obstruction of the small deep penetrating arteries. Symptoms depend on location, at times may be silent.
Subcortical infarcts are again infarcts, but involve different arteries located mainly in the subcortical white matter.
Microbleeds are not infarcts, not obstruction of an artery, they are bleeds due to rupture of an artery.
For all of these lesions the symptoms may be similar, like weakness of the limbs, numbness or loss of sensation, speech articulation difficulties, coordination issues etc depend on the location of the lesion. At times the patient may even not notice any symptom at that moment but still there is damage which contributes to the dementia which is seen in later stages. The distinction of the lesions is done by MRI, not visual evidence, visual evidence is used only to try and filter which cases are due to migrainous aura so that MRI is not ordered uselessly. If symptoms last for 4 days as you say then they shouldn't be due to aura but due to a lesion and I would order a MRI to differentiate which one.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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