What is migraine with aura?

Migraine with aura occurs  in about 30% of the total migraine population. It used to be called classical migraine. The syndrome consists of a vision of seeing spots, holes, half of things, or zig-zag lines. This is called a migraine aura which usually comes shortly before the headache starts, but it may be in the middle or end of the attack. This visual specter is very remarkable and persons who have had it can easily draw what they saw later.

The experience is riveted in their brain. In addition to the visual image migraine with aura persons my notice numbness or tingling usually starting in one hand or the other in the fingers, moving to the wrist, next the arm, and finally to the cheek or tongue on the same side.

Read my article on “Migraine with aura” on my website www.doctormigraine.com

Rare migraine with aura patients have trouble speaking or writing which is called aphasia. The is usually the rarest but scariest part of the migraine, yet the aura symptoms of vision, tingling, or speech are all short-lived, lasting from 10 to 30 minutes.

After the aura, the migraineur experiences a one-sided, severe, throbbing headache, nausea and vomiting, and sensitivity to light, sound, and odors lasting 4 to 72 hours. The migraine patient usually needs to be down and the headache is disabling for work or ordinary activity.

Migraine is considered to be a genetically inherited condition, found in families, found in women, and in our DNA.

This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, Migraine textbook author, Podcaster, YouTube video producer, and Blogger.

What is atrial fibrillation?

Atrial fibrillation is a serious heart condition that has a possible strong relationship with stroke. The heart is divided in 4 chambers, the right and left compartments called atria, and the right and left ventricles. Normally the heart has electrical wiring that spreads first to the atria, causing contraction and then to the ventricles. This 2-beat pattern gives the heart its characteristic sound-“lub, dub.”

With atrial fibrillation the heart does not beat regularly, the atria just fibrillate, which means a quivering movement that doesn’t move blood from the atria to the ventricle like it is supposed to. Blood can collect and clot if left in the atrium and then later the clot may drop down into the ventricle and be sent anywhere in the body, the brain, the left leg, the bowel.

The rhythm of atrial fibrillation is ‘irregularly irregular.” There is no normal rhythm, and it is hard to get a blood pressure reading also. Symptoms of atrial fibrillation can be chest pain, shortness of breath, heart racing, light headedness, an irregular heartbeat, or fatigue.

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TIA or stroke

This moving clot is called an embolus which moves internally through the aorta or arteries throughout the body. When it lands the embolus blocks fresh oxygenated blood from working where it is supposed to. If it is in an artery in the right leg, then the person feels numbness and weakness in the leg. If it is in the left carotid artery, the person may have trouble speaking (aphasia) or numbness or weakness of the right arm and leg.

The emboli when they land, wherever they are going may dissolve in a few minutes, freeing the blood supply. This may be a neurological event lasting usually less than 30 minutes and is called a warning of a stroke, a TIA, an eponym meaning Transient Ischemic Attack.

Transient refers to the short time the event may last, such as 30 minutes and the ischemic phrase means “lack of blood.”

So, persons with migraine with aura have an increase in TIA’s or warnings of stroke. All persons with atrial fibrillation should see their doctor and have a work-up of tests. Many of them will need to thin their blood with an anticoagulant medication. Some of them will need to have ablation (means removal/destruction) of their heart’s sinus node, the part of the heart that is the “sparkplug” and sends out the electrical beat through the heart.

Read my article on “Migraine and stroke” on my website, www.doctormigraine.com.

What causes the relationship between migraine with aura and atrial fibrillation?

The exact cause is not understood or figured out yet. It is known that there is a clinical relationship between migraine with aura and atrial fibrillation. These two conditions occur together. One study found that women with migraine with aura had a 30% higher risk of atrial fibrillation than women without migraine.

Atrial fibrillation affects millions of people worldwide, and its prevalence increases with age. Other common risk factors include high blood pressure, heart disease, obesity, diabetes, and a family history of the condition. Symptoms of atrial fibrillation can vary from person to person, ranging from palpitations and fatigue to shortness of breath and chest pain. Some individuals may not experience any noticeable symptoms, making it essential to diagnose and treat the condition promptly.

Other research proposes that migraines with aura and atrial fibrillation may share common underlying mechanisms. Both conditions have been associated with dysfunction in the autonomic nervous system, which regulates various bodily functions, including heart rate and blood pressure. Additionally, both migraines with aura and atrial fibrillation have been linked to inflammation and increased oxidative stress. These shared mechanisms could explain the observed association between the two conditions.

Triggers for migraine with aura and atrial fibrillation

Both conditions can be triggered by stress, alcohol, hormonal changes, lack of sleep, and environmental factors.

For migraine with aura, common triggers include bright lights, strong odors, loud noises, weather changes, heat, trouble sleeping. Avoiding these triggers can help reduce the frequency and severity of migraines.

Similarly, individuals with atrial fibrillation are often advised to avoid excessive alcohol consumption, caffeine, and certain medications that can exacerbate the irregular heart rhythm.

Managing both migraines with aura and atrial fibrillation requires identifying individual triggers and making necessary lifestyle modifications to minimize their impact on daily life.

Read my article on “Migraine triggers’” on my website., www.doctormigraine.com.

Diagnosing Migraine with Aura and Atrial Fibrillation

Accurate diagnosis of migraines with aura and atrial fibrillation is essential for effective management and treatment. Diagnosing migraine with aura typically involves a thorough neurologic and medical history and physical examination. The doctor may also order additional tests, such as brain imaging and blood work to rule out other possible causes of the symptoms.

Diagnosing atrial fibrillation typically involves an electrocardiogram (ECG) to detect abnormal heart rhythms. In some cases, additional tests like a Holter monitor or event recorder may be used to capture intermittent irregular heart rhythms that may not be detected during a standard ECG.

It's important to consult with your doctor if you suspect you may have either migraine with aura or atrial fibrillation to receive an accurate diagnosis and appropriate treatment.

Treatment Options for Migraine with Aura and Atrial Fibrillation

Treatment strategies for migraine with aura and atrial fibrillation aim to reduce symptoms, improve quality of life, and prevent complications. For migraine with aura, treatment options include over-the-counter pain relievers, triptans, CGRP antibody medication for acute and preventive medication. Lifestyle changes, such as stress management techniques, regular sleep patterns, can also help reduce the frequency and severity of migraine.

Read my article “Migraine Treatment 2023” on my website www.doctormigraine.com.

For atrial fibrillation, treatment options depend on the severity of symptoms and the presence of underlying heart conditions. Medications may be prescribed to control heart rate, restore normal rhythm, or prevent blood clots. In some cases, electrical cardioversion or catheter ablation may be recommended to restore normal heart rhythm.

Lifestyle modifications, such as regular exercise, a heart-healthy diet, and stress reduction, are also crucial for managing atrial fibrillation and reducing the risk of complications.

Preventing atrial fibrillation involves managing underlying risk factors. This includes controlling blood pressure, managing diabetes, maintaining a healthy weight, and treating any underlying heart conditions. Regular check-ups with a healthcare professional and adhering to prescribed medications are crucial for preventing complications associated with atrial fibrillation.

Medical articles

Chia-Chun Chiang, Todd J Schwedt, and David Dodick wrote on “Exploring the association between migraine and atrial fibrillation utilizing a novel artificial intelligence ECG algorithm” in Headache, 2022 Sep, 62(8):933-934.

This study found a relationship between migraine and atrial fibrillation using a new ECG algorithm,

Dr. Chiang spoke at the American Headache Society meeting in Denver saying, “Individuals who had migraine with aura were more likely to have atrial fibrillation compared with those who had a migraine without aura. The difference remains significant, after we adjusted for age, sex and six vascular risk factors, especially in those younger than 55 years [of age], in both women and in men.”

A Scutelnic, H P Mattle, M Branca, etc. wrote in Review Eur J Neurol on Migraine and atrial fibrillation: a systematic review in. 2022 Mar;29(3):910-920.

Abstract

Background and purpose: Patients with migraine are at increased risk of stroke. The aim was to systematically review the current literature on the association between migraine and atrial fibrillation, which is a relevant risk factor for stroke.

Methods: PubMed was searched for 'migraine' AND 'atrial fibrillation' and selected original investigations on the association of migraine and atrial fibrillation for our analysis.

Results: In all, 109 publications were found. Twenty-two were included and analysed for this review. Studies investigating patients with ischaemic stroke and migraine are methodologically insufficient and provide contradictory results. Ablation therapy for atrial fibrillation in patients with migraine might reduce migraine attacks, but transient post-ablation new-onset migraine-like headaches in persons without a history of migraine have also been reported.

The authors concluded:

Population-based studies indicate a significant association of migraine with aura and atrial fibrillation. In practical terms, screening for atrial fibrillation in patients who have a long history of migraine might be reasonable, whereas in patients with stroke or other disorders and migraine extensive screening for atrial fibrillation should be performed as in all patients without migraine.

M Chiang, O Dumitrascu, N Chhabra wrote in Review J Stroke Cerebrovasc Dis, in . 2021 Nov;30(11):106067, on Migraine with Visual aura and the Risk of Stroke- a Narrative Review.

Abstract

Objectives: Patients with migraine with visual aura (MwvA) often present to eye care providers for evaluation. A thorough ophthalmological history and examination is needed to exclude ophthalmologic disorders. Additionally, it has been increasingly recognized that MwvA is associated with ischemic stroke (IS). The aim of this narrative review is to provide a comprehensive overview of the differential diagnosis of MwvA and its association with IS.

Materials and methods: We conducted a PubMed search using key words including "migraine aura", "visual aura without headache", "late onset migraine accompaniment", "migraine and stroke", "migraine and atrial fibrillation", and "migraine and patent foramen ovale (PFO)".

Results and conclusion: For women younger than 50 years, MwvA is associated with an increased risk of IS, and the risk further increases in patients who also smoke and use oral contraceptives.

G Tietjen , E Maly wrote in Headache in. 2020 May;60(5):843-863, on .Migraine and Ischemic Stroke in Women. A Narrative Review

Abstract

Objective/background: Migraine is associated with ischemic stroke. Women are 3-fold as likely as men to have migraine, and high estrogen states increase the risk of migraine with aura (MWA), venous thromboembolism (VTE), and of stroke. We review the epidemiological and mechanistic evidence of the migraine-stroke relationship and its risk factors, with a focus on women and conditions that exclusively or predominantly affect them. METHODS: We performed a search of MEDLINE/PubMed database, then a narrative review of the epidemiological evidence of the migraine-stroke relationship as well as the evidence for arterial, thrombophilic, and cardiac mechanisms to explain this connection. We examine the implications of this evidence for the diagnostic evaluation and treatment of MWA.

Results: MWA is associated with multiple stroke risk factors, such as hypertension, hyperlipidemia, diabetes mellitus, cigarette smoking, atrial fibrillation, and patent foramen ovale. In women, MWA is also associated with biomarkers of endothelial activation, hormonal contraceptive use, pregnancy, and VTE. This suggests that a subset of auras may be secondary, that is, induced by ischemia related to microemboli or in situ thrombosis. MWA-associated ischemic stroke is more common in young (<45 years old) women with high frequency of migraine attacks, hormonal contraception use, and with pregnancy and preeclampsia. There is increasing evidence that cardioembolism, often in conjunction with thrombophilia, plays a prominent role in MWA-associated cerebral infarction.

Conclusion: The commonality of factors associated with MWA and with MWA-associated stroke suggest that persons with secondary, ischemia-induced aura may be at elevated risk of stroke. Although further research is needed, we recommend consideration of a diagnostic evaluation of MWA that mirrors the evaluation of transient ischemic attack, given that prophylactic treatment targeting the ischemic origin of secondary aura may prevent migraine as well as stroke.

Conclusion:

There is ample medical data certifying the stroke proclivity associated with migraine with aura and atrial fibrillation. Patients with both of these problems should harken to the provided research and comments. Atrial fibrillation alone or with migraine with aura is always a problem that should be embraced with neurological and cardiac evaluation.

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 Britt Talley Daniel MD