Differences in treatment response between migraine with aura and migraine without aura: lessons from clinical practice and RCTs

Jakob Møller Hansen,Andrew Charles

doi:10.1186/s10194-019-1046-4

Abstract

Migraine is a major public health problem afflicting approximately 10% of the general population and is a leading cause of disability worldwide, yet our understanding of the basis mechanisms of migraine remains incomplete. About a third of migraine patients have attacks with aura, consisting of transient neurological symptoms that precede or accompany headache, or occur without headache. For patients, aura symptoms are alarming and may be transiently disabling. For clinicians and scientists, aura represents an intriguing neurophysiological event that may provide important insight into basic mechanisms of migraine. Several observations point toward important differences between migraine with and without aura. Compared with migraine without aura, migraine with aura has different heritability, greater association with different conditions including stroke, different alterations of brain structure and function as revealed by imaging studies. A number of studies also indicate that migraine with aura may respond differently to acute and preventive therapies as compared to migraine without aura. The purpose of this review is to provide an overview of these differences in treatment responses, and to discuss the possibility of different therapeutic strategies for migraine with vs. without aura.

Highlights

BackgroundMigraine is the most prevalent neurological disease [1] afflicting a large part of the population across the world [2] and ranks the 2nd leading cause of years lived with disability [3] especially in the young and middle-aged [4]
Migraine is the most prevalent neurological disease [1] afflicting a large part of the population across the world [2] and ranks the 2nd leading cause of years lived with disability [3] especially in the young and middle-aged [4].Migraine has been vividly depicted since the dawn of medicine with the first accounts of attacks of migraine with aura dating back more than two millennia [5]
Imaging studies suggest that structural brain changes are more prevalent in those with migraine than in controls, and some of these changes are most pronounced in migraine with aura [10]

Summary

Background

Migraine is the most prevalent neurological disease [1] afflicting a large part of the population across the world [2] and ranks the 2nd leading cause of years lived with disability [3] especially in the young and middle-aged [4]. Several observations point toward important differences between migraine with and without aura. Cerebral blood flow changes may differ between migraine with and without aura [11, 12]. Regardless of the answer to this question, there may be differences in therapeutic responses of individual attacks to acute therapies, and in the efficacy of preventive approaches for migraine with vs without aura. Up to 1/3 of migraine patients experiences aura [13]; reversible transient focal neurological symptoms arising from the cortex or brainstem [14]. Clinical observations suggest a high degree of clinical variability in migraine aura both between patients [16] and from one attack to the [17]. The aura is often perceived as having a “spreading” character (Fig. 1), and aura symptoms normally occur in succession suggesting an underlying mechanism that propagates slowly through adjacent brain tissue

At least two attacks fulfilling criteria B and C

Findings

Conclusion