Acta Neurol Scand.

, 1986:73:359-362
Key words: aura symptoms; classic migraine; prospective
recording.

Classic migraine
A prospective recording of symptoms

K. Jensen', P. Tfelt-Hansen2, M. Lauritzen2,

J. Olesen'
'Department of Neuromedicine, Gentofte Hospital,
and Wigshospitalet, University of Copenhagen,
Denmark

ABSTRACT - Systematic prospective records of aura symptoms were obtained from

50 patients, who filled in report forms during the aura phase of two attacks. The
pattern of the various aura symptoms was remarkably constant during two attacks.
Visual aura was recorded by 94% of the patients, somato-sensory aura symptoms by
40%, motor disturbances by 18% and speech difficulties by 20%. Visual aura was
unilateral in 5 5 % , somato-sensory aura symptoms were unilateral in 80% and motor
aura was unilateral in 100%. Surprisingly, headache was absent in 20% of the aura
attacks. When unilateral headache and unilateral aura symptoms occurred in the
same attack, headache was most often contralateral to the somato-sensory and
motor aura symptoms. Our observations are in accordance with the hypothesis that
the pathophysiological process responsible for the aura symptoms in classic migraine
starts at the visual cortex.

Accepted for publication November I I , 1985

Classic migraine is characterized by recurrent
attacks of headache, preceded or accompanied
by reversible focal neuiological symptoms. In the
medical literature, descriptions of these clinical
characteristics rest largely on retrospective stud-
ies or clinical experience in general, (1-3). We
were thus unable to find prospective studies.
During a clinical trial of Nimodipine for the
treatment of singular attacks of classic migraine
(4), therefore we recorded prospectively the aura
symptoms experienced by patients during two
attacks.
Material and methods
The trial itself was a double-blind, randomized,
placebo :controlled cross-over study, where each
patient had to treat two attacks with test medica-
tions taken on recognition of the usual aura
symptoms. The test medication therefore could
not influence the presence and localisation of
aura symptoms. Seventy-nine patients (61 fe-
males and 18 males) were selected from the
Copenhagen Acute Headache Clinic and two
private clinics on the basis of a clear diagnosis of
classic migraine with well-defined aura symptoms
lasting at least 15 minutes. Classic migraine was
defined as recurrent attacks of headache, pre-
ceeded by reversible focal neurological symp-
toms. Patients also fulfilled the criteria laid
down by the Ad Hoc Committee on Classifica-
tion of Headache ( 5 ) . Fifty patients were treated
for one attack and 40 patients were treated for
both attacks. Neither the groups nor the drop-
outs differed significantly from the original
material with regard to any of the characteristics
listed in Table 1.
360 K. JENSEN ET AL

Frequencyof aura symptoms and headache

Results
Visual Somate Motor Speech Headache

604
sensory
n Aura symptoms
The frequency of observed aura symptoms is
shown in Fig. 1. There was no difference
between the frequencies observed during the 2
attacks. The somatosensory and motor aura
symptoms were more often unilateral than bilat-
eral 0, < 0.05). This was not observed in the
visual aura symptoms.
The consistency of a particular aura symptom
and its location may be read from Tables 2 and
2a which show the location of aura symptoms in
Attack 2 compared to the same patient's record
during Attack 1.
During Attack 1, 28 patients experienced only
one type of aura symptom (28 visual), 13 patients 2
types (11 including visual), 6 patients 3 types (5
including visual) and 3 patients all 4 types. The
Fig. 1. Frequency of aura symptoms recorded during pattern of coexistence of aura symptoms is shown
initial interview (n = 50, 0,
during Attack 1 (n = SO),
R and during Attack 2 (n = 40), H.
Above X-axis, unilateral occurrence, below X-axis
bilateral occurrence, m. Table 2
*) unilateral occurrence significantly more frequent Number of patients with a particular location of aura symptom
in Attack 2 compared to Attack 1. n = 40.
than bilateral occurrence, (Chi-square, p < 0.05).
Somato-
Visual Motor Speech
sensory
Statistical evaluation Unilateral same side 12 6 4 5
Chi-square Test was used for evaluation of Unilateral opposite side 5 2 2
results. p < 0.05 was chosen as the level of Unilateral versus bilateral 5 1 0
significance. Unilateral versus absent 0 3 2 2
Bilateral as before 11 2 0
Table 1 Bilateral versus unilateral 4 0 1
Clinical variables and attack characteristics of the material Bilateral versus absent I I 0
obtained at initial interview (median and range) Absent as before 2 20 29 31
~

Absent versus unilateral 0 5 2 2

Number of patients 79 Absent versus bilateral 0 0 0
Age (years) 37
(16-68)
Frequency of attacks 18
(per year) (2-104) Table 2a
Length of usual aura 30
Somato-
(min) (15-300) Visual Motor Speech
sensory
Length of usual attack 24
(h) (I - 192) Present or absent during
Migraine history 16 both attacks 98%" 78%* 90%' 90%"
(years) (1-52) Consistently either
Unilaterality 0.71 unilateral or bilateral
(ratio) in both attacks 76%" 91%" 86% -
Pulsating quality 0.66 When unilateral in both
of pain (ratio) attacks, then consistently
Nausea and/or 0.84 on the same side 11% 15% 61% -
vomiting (ratio)
*) Chi-square, p < 0.05.

in Table 3. When 2 types of unilateral aura symp-
toms were recorded during Attack 1, 8 of 10
patients having visual and somatosensory symp-
toms had these on the same side. Likewise, 7 of 7
patients had somatosensory aura symptoms
ipsilateral to their motor symptoms. Three of 4
patients with visual and motor aura symptoms
experienced these on the same side.
Headache
Headache was always claimed to occur in the 50
patients during interview, but was absent in 10
during Attack 1 and in 7 during Attack 2. In 3
patients, headache occurred neither in Attack 1
nor 2. The distribution of headache is shown in
Fig. 1.
Aura symptoms and headache
In 47 patients with visual aura, headache occur-
red in 40, unilaterally in 64%. In 20 patients with
somato-sensory aura, headache occurred in 14,
unilaterally in 86%. In 9 patients with motor
aura, headache occurred in 8, unilaterally in
loo%, and in 10 patients with symptoms of
speech, 8 developed headache, unilaterally in
75070. Table 4 shows the co-occurrence of aura
symptoms and headache. With unilateral aura
symptoms, headache was significantly more
often unilateral than bilateral 0, < 0.05).
Discussion
The visual aura symptoms were present in 95%
of the attacks and in only 2 patients was visual
aura consistently absent. This indicates that the
Table 3
Frequency of co-existing aura symptoms given the presence of
one (Attack 1)
Somato-
Visual Motor Speech
sensory
Visual
n = 41 36% 19%
Somato-
sensory
n = 20 85 To 40% 40 "70
Motor
n = 9 I8 To 89 % 56%
Speech
n = 10 80To 80 % 60TO
CLASSIC MIGRAINE 361
visual cortex is of primary importance with
regard to the pathophysiological processes under-
lying the aura symptoms and corresponds well to
the frequent findings of reduced cortical blood
flow in this particular region during aura symp-
toms of classic migraine (12). The less often
recorded somatosensory and the rather rare
motor deficiences as aura symptoms, and espe-
cially the observed pattern of coexistence of
more than one type of aura symptom, may indi-
cate that the underlying pathophysiological pro-
cess starts at the occipital cortex and moves ante-
riorly to varying degrees in the different attacks,
although the exact timing of co-existing aura
symptoms was not recorded. It appeared that the
visual cortex, contrary to the other parts of the
hemispheres was often bilaterally affected (45 @lo
of patients with visual aura) or at least that the
visual symptoms often appeared bilateral to the
patients. The latter might be explained by the
patients' difficulty in determining distinct areas
in the visual field as malfunctioning.
Our records of speech difficulties were not
specific in the sense that it was unknown whether
aphasia or dysarthria accounted for the symp-
toms. A more detailed study is needed, but this is
hardly realistic since it would also require a
qualified observer, which makes it almost impos-
sible to obtain detailed information of speech
difficulties during classic migraine.
Regardless of the treatment given, 20% and
28% in Attacks I and 2 respectively did not
develop headache. This may of course in part be
Table 4
Distribution of headache with different types and distributions
of aura symptoms
~
Headache
Aura symptoms Unilateral
Contra-
lpsilateral lateral Bilateral Absent
17% Unilateral visual 13 I 2 4
Unilateral
somato-sensory 3 6 I 6
Unilateral motor 3 5 0 1
Bilateral visual 10 7 4
Bilateral somato-
sensory 3 1 0
Bilateral motor 0 0 0
362 K. JENSEN ET AL
explained by a “placebo effect” of the test medi-
cation but may also indicate that aura symptoms
without headache occur more often than hitherto
believed. Patients with unilateral aura symptoms,
and unilateral headache contralaterally to these
aura symptoms, did not represent the majority.
When both aura symptoms and headache were
recorded as unilateral, only 1/3 of those with
visual aura had contralateral headache whereas
contralateral headache predominated with uni-
lateral somatosensory and motor aura symp-
toms. This is in contrast to observations by Peat-
field et a1 (6), who in 75 patients with unilateral
headache and unilateral sensory or motor symp-
toms, found a marked tendency to headache
occurring on the ipsilateral side.
With visual aura symptoms, the headache was
less specific with regard to location than when
the aura symptoms could be referred to the cere-
bral convexities. This might indicate that the
actual nociception took place close to the cortical
areas affected. The anatomical arrangement of
visual cortex on the mesial surface of the hemi-
spheres and the other symptomatic areas on the
convexities might explain why headache is more
often bilateral with visual aura symptoms than
with somatosensory and motor aura. Further
prospective studies with detailed recordings of
aura symptoms and headache are needed to see
which of the various pathophysiological models
best fits the clinical picture.
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Address
Kai Jensen
Department of Neuromedicine
Gentofte Hospital
2900 Hellerup
Denmark