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Double vision as a migraine aura

Until 1988, doctors could essentially create their own definition of headaches. This only changed when the International Headache Society (IHS) published a catalog of numerous diagnostic criteria. This catalog is now also included in the ICD-10, the International Classification of Diseases (10th edition), published by the World Health Organization (WHO). A first revision, the second edition, was published by the International Headache Society in 2004.

Looking at the main categories of this classification alone, we find 13 different primary groups of headaches. One level deeper, we already find 36 subcategories, and with a very precise diagnosis, we can identify over 250 different types of headaches.

Double vision as a migraine aura (Photo: Dr. Angelika Demel)

If all these types of headaches were treated in the same way, such a differentiated classification would, of course, be nothing more than a toy for medical pedants. But that's not the case. It's obvious that a headache caused by high blood pressure should be treated by lowering blood pressure, or a headache resulting from bacterial meningitis with an antibiotic.

However, many people not only struggle to differentiate between such rather specific types of headaches, but even to correctly diagnose the two major groups “tension-type headaches” and “migraine”, which together account for a good ninety percent of all headaches.

Tension-type headache or migraine?

A thorough examination is essential for the doctor to rule out so-called symptomatic headaches. These are headaches that occur as a symptom of another illness. The pain could, after all, be a consequence of a flu-like infection, a toxic substance, or even a brain tumor. Once these types of headaches have been ruled out, and the patient can provide detailed information—for example, using a headache diary—about when and how often the pain occurs and what accompanying symptoms it has, then distinguishing between tension-type headaches and migraines is essentially very straightforward.

The main difference between migraine headaches and tension-type headaches lies in their duration: A migraine attack usually lasts no more than 72 hours, while untreated tension-type headaches can last from 30 minutes to seven days. The nature of the pain also differs: While migraines are characterized by throbbing, pulsating, or pounding pain, tension-type headaches are more often dull, pressing, or pulling. The intensity also differs: While a migraine attack usually severely restricts normal activity, this is not necessarily the case with tension-type headaches. Migraine sufferers seek bed rest, whereas tension headaches are often relieved by exercise in the fresh air.

A crucial criterion is the occurrence of nausea and vomiting, as well as sensitivity to light and noise. Nausea and vomiting do not occur with tension-type headaches, while sensitivity to light or noise is possible but not typical.

This can only be determined, of course, once the headaches have occurred at least five times and the patient can provide a fairly precise description of the pain's progression. And naturally, there are people who suffer from both migraines and tension-type headaches. In such cases, it's important to identify and treat both types of headaches appropriately.

Chronic migraine is a special case and, in a sense, a complication. It occurs on 15 or more days per month for at least three months. Medication overuse has been ruled out. Chronic migraine usually develops only as a consequence of years of suffering from a headache disorder.

If you suffer from headaches, you should keep a diagnostic headache diary. By doing this diligently, you can continuously identify your headache type and discuss it with your doctor. You can then retrospectively record your experiences in the diagnostic headache questionnaire. This will help you determine whether you suffer from migraines or tension-type headaches.

Warning signs of migraine

Sensory overload before the seizure

Nearly a third of migraine sufferers experience symptoms up to two days before a migraine attack, warning signs of the impending attack. These warning signs can vary greatly: severe irritability, cravings for sweets, frequent yawning, restlessness, fatigue, and much more.

When a migraine attack begins, it's natural for patients to see the warning symptoms as the trigger or even the cause of the migraine – for example, stress in the case of irritability, chocolate in the case of a craving for sweets, or lack of sleep in the case of preceding fatigue. But that would be a misconception. These are not triggers of the migraine attack, and certainly not its causes. Rather, they are simply the first nonspecific symptoms of a migraine.

Aura: When nerves go haywire

In one out of ten migraine sufferers, the attack begins with disturbances of the central nervous system, known as an "aura ." These disturbances develop within a few minutes and usually last a maximum of one hour. If several disturbances occur in succession, the durations add up and can then exceed one hour. In a special form of migraine—"migraine with prolonged aura"—the disturbances also last longer: between 60 minutes and seven days.

But what exactly is an aura? The phenomenon was named after Aurora, the Greek goddess of the dawn. Before the headache attack, neurological disturbances gradually intensify over 15 to 30 minutes, similar to a sunrise. Most often – in about 90 percent of cases – these are visual disturbances. Shimmering spots or zigzag lines, streaks, or veils suddenly appear at the periphery of the visual field and gradually spread. However, the aura can also manifest as dizziness, speech difficulties, tingling in certain parts of the body, or even paralysis.

The migraine aura gets its name from Aurora, the Greek goddess of dawn: This link provides more information about Aurora and the associated visual phenomena. It resembles the visual phenomena experienced by migraine sufferers during the aura phase.

The headache usually follows the aura symptoms. However, it can also be completely absent. Some patients complain of one or more aura symptoms for years without even remotely suspecting that they suffer from migraines. Because the symptoms usually last no longer than ten to thirty minutes, patients often don't consider it necessary to consult a doctor.

You might now think that the aura is also a warning sign of migraine, as I described in the last section. But that's precisely what it isn't. As you will learn in more detail, migraine is a disorder of the nervous system. This neurological condition usually manifests itself in the form of the typical throbbing headaches, but also in the aura symptoms. These are therefore the migraine itself, not warning signs. And they are so typical, occurring in this form only with migraine, that they are an absolutely clear indication that the headaches that usually follow are indeed headaches within the context of a migraine.

The headache phase and its characteristics

The migraine attack

There are two possible explanations for the word "migraine." One suggests it derives from the Greek "hemikrania" (hemi = half, kranion = skull), because migraine pain occurs on only one side of the head in about half of all sufferers. The other explanation traces the word's origin to the Latin "migrare," meaning "to wander" or "to roam." This theory is plausible, as all phases of a migraine share a phenomenon already observed in the aura: a gradual spread or migration. In the aura phase, for example, the tingling sensation begins in the fingertips and spreads slowly, like the dawn rising from the sky, up the entire arm to the tongue.

Pain is a restless wanderer

The same phenomenon occurs during the headache phase. The pain can also migrate: at the beginning of an attack, it might be diffusely distributed from the neck across the entire skull, only to manifest itself later in the attack in different areas of the head – including, for example, the upper and lower jaw. At the peak of the attack, however, it is felt at its individually varying main location, before gradually retreating to its starting point via various intermediate stages as the attack progresses.

During its progression, the nature of the pain often changes. At the beginning and towards the end of an attack, it can be dull, pulling, or pressing – quite similar to a tension-type headache. At the peak of the attack, however, when the pain has reached its main location, it almost always corresponds to the typical migraine pain with its throbbing character and reaches an intensity far exceeding that of a tension-type headache.

The Migraine Attack (painting by Dr. Angelika Demel)

Every movement intensifies the pain

A typical characteristic of migraines is that the pain worsens with every movement. Those suffering from tension headaches might find relief with a walk in the park or some light exercise. Not so for migraine sufferers: any physical exertion, even just going to the toilet, makes the pain even more unbearable. The same applies to sneezing, coughing, or vomiting. This characteristic of migraine pain is so typical that it can even be used to distinguish it from other types of headaches.

Duration and frequency of attacks

The actual pain phase of a migraine can last from four to 72 hours. In most cases, however, the pain subsides after about a day. Only about ten percent of patients actually suffer from the excruciating pain for up to three days. If the attack lasts longer than three days, it is referred to as "status migrainosus" (a persistent migraine-like state). This is not the norm, however, but a complication of a "normal" migraine.

On average, migraine sufferers experience one to two attacks per month. Only about eight percent of those affected have more than three attacks per month. However, the frequency of attacks can fluctuate considerably in the same person over time. There may be periods in which the frequency of attacks decreases significantly, and others in which it increases.

Accompanying symptoms add to the burden

One of the most characteristic accompanying symptoms of a migraine attack is nausea, which affects 65 to 95 percent of sufferers, depending on the study. Vomiting occurs in almost 50 to 60 percent of attacks. The remaining patients—those who suffer from neither nausea nor vomiting—at least experience a loss of appetite. It should be noted that patients have very different understandings of "nausea." Some, for example, equate nausea with vomiting, while others understand it as an aversion to food or pressure in the stomach area. These differing definitions alone result in the wide range of typical accompanying symptoms, from loss of appetite to vomiting, which also includes heartburn, bloating, and abdominal pain. What is certain, however, is that no migraine patient experiences intense cravings for specific foods during an attack. This only occurs during the prodromal phase.

When petting becomes torture

A general hypersensitivity of the senses is also typical of a migraine attack. This usually manifests as sensitivity to light and/or noise. Between 61 and 98 percent of patients complain of a strong aversion to loud noises alone. However, this aversion can also extend to smells, so that even subtly applied perfumes can cause nausea. An aversion to touch is also frequently observed. Even if a partner's sympathetic caress is well-intentioned, the migraine sufferer may experience it as excruciating torture.

Interestingly, the severity of the accompanying symptoms is directly related to the intensity of the pain. In other words: the worse the accompanying symptoms, the more intense the pain, and vice versa.

Other possible accompanying symptoms

In addition to these typical accompanying symptoms, others may occur:

• During an attack, the facial skin appears extremely sallow and pale. The cheeks are sunken, and the skin looks dry, strained, and withered.
• The eyes may lose their shine and begin to water. They appear lifeless and sunken overall.
• The throbbing, pulsating pain can also occur in the sinuses or the nasopharynx. Some patients experience excessive nasal mucus production, leading to nasal congestion. Conversely, a dry nose and burning sensation in the nose can also occur.
• During attacks, the whole person suffers – not only physically, but also psychologically. Negative feelings such as depression, anxiety, anger, and others gain the upper hand, pushing positive moods like self-confidence and compassion into the background.
• Some patients experience weight changes due to altered fluid intake and excretion.
• Some patients begin to feel chills, shiver, or sweat during attacks. It is unclear whether this is accompanied by an actual change in body temperature or whether it is "only" a subjective perception of those affected.

The migraine doesn't end after the pain subsides

Even after the migraine headache subsides, the attack is not yet over. Almost all patients subsequently suffer from severe exhaustion, fatigue, and lethargy for up to one or two days, as well as a desire to be alone.

Furthermore, increased pain sensitivity is often observed. For example, combing the hair can be extremely painful, or sharp, stabbing pains may occur in the head (so-called "ice pick headache"). All in all, most patients need a period of rest with plenty of sleep after an attack.

The images on this page were kindly provided by Dr. Angelika Demel, physician in Günzburg. She uses them to illustrate her own migraine.