Brainstem (outlined in red)

NDR Visite – Adventure Diagnosis reports on a patient who had unclear and complex neurological symptoms with headaches for years. Among the 47 different subtypes of migraine, migraine with brainstem aura is often difficult to distinguish from other diseases. So-called brainstem symptoms such as dizziness (vertigo), hearing noises (tinnitus), bilateral sensory and motor disorders as well as the inability to speak (dysarthria), swallow (dysphagia) and double vision (diplopia) can occur. Corresponding symptoms are sometimes difficult to differentiate from transient ischemic attacks (TIA) or stroke.

Not easily recognized in everyday life are brainstem symptoms such as dizziness, tinnitus, bilateral sensory and motor disorders as well as dysarthria, dysphagia and diplopia. Corresponding symptoms can be observed in migraine with brainstem aura , and this form is sometimes difficult to distinguish from transient ischemic attacks (TIA). However, it helps to differentiate that patients with migraine with brainstem aura are usually in the second and third decades of life , there are no vascular risk factors , the headache in migraine with brainstem aura is severe , and the headache outlasts the neurological symptoms for a long time .

If the supply area of ​​the basilar artery is affected, bilateral motor disorders can occur. In addition, visual disturbances may be present in both the temporal and basal visual fields of both eyes, as well as dysarthria, dizziness, hearing noise, hearing loss, diplopia, ataxia, bilateral sensory disturbances in the form of paresthesias, loss of consciousness and even coma. In individual cases, other symptoms have also been described, such as cerebellar disorders, tremor, nystagmus, retinal degeneration, deafness and ataxia.

In addition to the visual aura, migraine with brainstem aura a common expression of migraine aura in childhood In children, neurological disorders occur in the form of bilateral visual field disorders, loss of tone, nystagmus, double vision, dysarthria and impaired consciousness . Although the attacks usually occur at long intervals, they can last 24 to 72 hours. Particularly in the case of such accompanying neurological disorders, a careful examination by a neurologist necessary in childhood.

The following are particularly the differential diagnosis : a tumor in the posterior cranial fossa , medication side effects (e.g. antiemetics), mitochondrial disorders and metabolic diseases .

Details on the distinction between migraines and transient ischemic attacks (TIA) can be found here:

Göbel CH, Karstedt SC, Münte TF, Göbel H, Wolfrum S, Lebedeva ER, Olesen J, Royl G. Explicit Diagnostic Criteria for Transient Ischemic Attacks Used in the Emergency Department Are Highly Sensitive and Specific. Cerebrovasc Dis. 2021;50(1):62-67. doi: 10.1159/000512182. Epub 2020 Dec 4. PMID: 33279892.

diagnostic criteria apply to migraine with brainstem aura :

Terms used previously

basilar artery migraine; basilar migraine; Basilar type migraine.


A migraine in which the aura symptoms are clearly attributable to the brainstem and there is no motor weakness.

Diagnostic criteria:

  1. Attacks that meet the criteria for 1.2 Migraine with aura and Criterion B below
  2. Aura in which both points below are met:
    1. At least 2 of the following fully reversible brainstem symptoms:
      1. Dysarthria1
      2. dizziness2
      3. Tinnitus
      4. Hearing loss3
      5. Double vision4
      6. Ataxia that is not due to a sensory deficit
      7. Impaired consciousness (GCS ≤13)5
    2. No motor 6 or retinal symptoms.


  1. Dysarthria should be differentiated from aphasia.
  2. Dizziness does not include drowsiness and must be distinguished from it.
  3. This criterion is not met if patients report a “feeling of fullness” in the ear.
  4. Diplopia does not include (or exclude) blurred vision.
  5. An assessment of the impaired consciousness according to the Glasgow Coma Scale (GCS) may have already been made upon admission; Alternatively, deficits clearly described by the patient allow GCS classification.
  6. If motor symptoms are present, the disease is coded under 1.2.3 hemiplegic migraine.


The terms basilar artery migraine or basilar migraine were originally used, but since involvement of the basilar artery is unlikely, the term migraine with brainstem aura should be preferred.

During most attacks, typical aura symptoms occur in addition to the brainstem symptoms. Many patients who have attacks with brainstem aura also report other attacks with typical aura. Here, both 1.2.1 Migraine with typical aura and 1.2.2 Migraine with brainstem aura should be coded.

Many of the symptoms listed under criterion B1 can be misinterpreted as they can also occur in conjunction with anxiety and hyperventilation.

The genetic predisposition with specific risk factors increases the individual's willingness to react with migraine attacks. The seizure itself is characterized by an episodic dysfunction of the brainstem in the area of ​​the trigeminothalamic projections. The trigeminocervical complex is activated and modulates the nociceptive input from the extracerebral intracranial vessels and the dura mater. Muscular hyperpathy and allodynia as well as central sensitization arise from projections of the upper cervical nerves (C1, C2) into the spinal trigeminal nucleus. The release of neuroinflammatory neuropeptides and activation of neurotransmitters in the area of ​​the extracerebral intracranial vessels and the dura mater results in vascular hyperpathy and allodynia with the development of the migraine headache phase. By inhibiting inflammatory neuropeptides, acute interventions during migraine attacks can therapeutically modulate symptoms. Preventive treatment measures aim to reduce sensitization in the trigeminocervical complex and to activate descending cortical pain control mechanisms.