The Complexion of Silent Migraine

An interesting case today. A semi-regular patient (78 years of age), having experienced a 20’-30’ episode of a visual disturbance involving the [L] eye exclusively 5 years ago (which was, by default, attributed to as a trans ischemic attack (TIA)), presented with visual disturbance commencing two and a half weeks ago.

The History

I have seen this patient at extended intervals for her ‘jelly-legs’ and balance issues successfully; however, there is a return of milder versions of her symptoms roughly every six months.

Upon arriving at a major teaching hospital, she underwent extensive investigations, including those by the stroke (CVA) team, which returned unremarkable results. She had and was undergoing a high-dose course of warfarin for an unidentified blood clot behind the eye.

This lady is well-educated and researched. After being told that her vision in her [L] eye would not recover and that she had experienced significant improvement in preexisting non-painful symptoms with my treatment, she felt that her neck was worth investigating. A fall in the garden 10/7 ago, resulting in obvious [L] upper cervical discomfort, compounded this complexity.

It is well-recognised that migrainous auras typically last between 20 to 30 minutes, but there are exceptions. In most cases, the aura resolves within an hour. However, in rare instances, auras can persist for much longer, even days or weeks. This condition is called ‘Persistent Aura Without Infarction’ (PAWOI).

Persistent Aura Without Infarction (PAWOI); A Red Flag?

Persistent aura without infarction is a rare phenomenon without signs of a stroke or other neurological damage. Symptoms can last for an extended period (longer than one week) and resemble a typical aura. They may include visual disturbances and other auras, such as sensory changes or speech difficulties. However, they do not resolve within the typical timeframe.

It is not surprising, given that the exact cause of a typical aura is not fully understood, PAWOI is believed to involve prolonged cortical spreading depression (a wave of electrical activity in the brain) or other neurological mechanisms.

The Red Flag Ruled Out

As with my patient, it is crucial to rule out other serious conditions, such as a CVA or a TIA, through imaging and clinical evaluation. This has been completed.

Generally, if an aura lasts longer than an hour or is accompanied by unusual symptoms (e.g., weakness, confusion, or severe headache), it is essential to seek medical attention immediately. As with my patient, she organised an ambulance when this occurred because prolonged aura symptoms could indicate other underlying conditions that require prompt evaluation.

Are Cervical Afferents Involved?

Manual therapy aimed at the correction of C2 rotation was completed successfully.

I have just finished a call with my patient. Twenty-four hours later, the post-treatment journey has been mixed but exciting for my patient (and Me!)

The consultation was yesterday at 9:30 a.m. She reported significant improvement for the rest of the day, but when she woke up today, she was dizzy (a pre-existing symptom) and had a stressful day. The improvement in one of her visual symptoms had deteriorated to pre-treatment status; another had not returned!

Stay tuned!

While most auras are short-lived, exceptions like PAWOI exist. If you or someone you know experiences an aura lasting days or weeks, it is essential to consult a healthcare professional to rule out other causes and ensure appropriate management. This information draws on empirical experience and is intended solely for educational purposes; it should not be interpreted as specific clinical advice or recommendations for individual patient care. Each patient’s situation is unique, and healthcare professionals must rely on their clinical judgement, training, and the specific circumstances of their patients when making assessment, management, and treatment decisions. If you have any concerns or questions regarding patient care, it is vital to refer to an appropriate healthcare professional or specialist.