Basilar migraine is a special variant of migraine caused by transient pathological changes in the blood supply area of the basilar artery. A headache attack occurs after an aura, which includes dizziness, ataxia, sensory disorders, visual disturbances, hearing impairment. Diagnosis is carried out by methods of neurological examination, REG, ultrasound or MRI angiography, MRI or CT brain and spine, surdological and vestibulological studies. Basilar migraine is stopped by inhalation of a mixture of oxygen and carbon dioxide, taking prednisone. In the interparoxysmal period, preventive treatment is carried out.
G43.1 Migraine with aura [classic migraine]
Basilar migraine is a rather rare severe form of migraine, fraught with the development of a number of complications, the most dangerous of which is an acute violation of cerebral circulation by the type of ischemic stroke. Basilar migraine is a migraine with aura. This variant of migraine got its name due to the fact that its aura is dominated by symptoms characteristic of damage to cerebral structures supplied with blood by the basilar artery of the brain. Similar basilar manifestations occur in 60% of cases of familial hemiplegic migraine, occurring with muscle weakness. For this reason, one of the cardinal distinguishing features of basilar migraine is the absence of motor deficiency.
Basilar migraine is most often observed in the age range of 18-50 years, but it can occur in children and in people over 50 years of age. Mostly women suffer. The peculiarities of pathogenesis and clinic cause certain difficulties experienced by specialists in the field of neurology in the diagnosis and therapy of the basilar variant of migraine.
The factors under the influence of which basilar migraine develops are uniform for all types of migraine paroxysms. These include: psycho-emotional overload, excessive consumption of energy drinks and coffee, nicotine addiction, violation of the normal daily routine, chronic lack of sleep, genetic predisposition; in women — taking contraceptives, hormonal restructuring.
Along with this, many patients have an anamnestic indication of a spinal injury in the cervical region or there is a pathology of the cervical region: abnormalities of spinal development, craniovertebral abnormalities (for example, Kimberly anomalies, Chiari anomalies), instability of the spine in the cervical region. This suggests a certain role of cervical nociceptive impulses in the occurrence of basilar migraine paroxysms.
Traditionally, in the pathogenetic aspect of the occurrence of a migraine attack, the main role is assigned to reflex vasomotor disorders. According to this concept, basilar migraine occurs in connection with similar disorders in the basilar artery, which supplies blood to the structures of the brainstem, occipital lobes, cerebellum and the labyrinth of the inner ear. At the same time, a number of researchers believe that basilar migraine is closely related to the hydropsis of the labyrinth — the reaction of its epithelium to constant nociceptive irritation, causing the development of endolymphatic edema. It is the involvement of the labyrinth that is associated with the high frequency of vestibular dysfunction and the presence of cochlear neuritis in a number of patients with basilar migraine. On the other hand, hydrops can be a complication of migraine.
Basilar migraine is characterized by the presence of an aura that includes at least 2 of the following symptoms: dizziness, tinnitus, diplopia, ataxia, hearing loss, dysarthria, disorder of consciousness, sensory disturbances, bilateral visual phenomena (flashes of light, spots) or amaurosis. Each of the above signs is transient and lasts at least 5 minutes . In some cases, there is a consistent occurrence of a number of aura symptoms, but its total duration does not exceed 1 h. Transient focal neurological deficit is noted in about half of patients. In rare cases, prolonged aura (up to 8 hours) is possible, continuing against the background of headache.
The aura is followed by intense, usually unilateral, cephalgia (headache). As a rule, basilar migraine is characterized by a pulsating type of cephalgia in the occipital region. However, in a number of patients, the headache has a non-occipital localization. In a significant part of patients, aura proceeds significantly more severely than the rest of the migraine paroxysm, and therefore some of them do not even mention cephalgia in their complaints, which significantly complicates the primary diagnosis of migraine. Nausea and vomiting, as well as light and sound phobia occur in only a third of patients. Possible short-term loss of consciousness (fainting) followed by retrograde amnesia.
Basilar migraine has a stable course with the occurrence of paroxysms every few weeks, monthly or at intervals of several months. With age, there is a decrease in the intensity and duration of migraine attacks. Complications of basilar migraine can be vestibulocochlear syndrome associated with labyrinth hydrops, homolateral cephalgia, sensorineural hearing loss, ischemic stroke in the vertebrobasilar basin.
Basilar migraine is diagnosed by a neurologist based on the patient’s anamnesis and interview, provided that there are no pathological changes in the neurological status outside of migraine paroxysm. One of the most important criteria that determines basilar migraine is the absence of any organic pathology of the brain (intracerebral tumor, encephalitis, cerebral cyst, brain abscess, hydrocephalus). In order to exclude it, CT or MRI brain is performed. Electroencephalography makes it possible to assess the functional state of cerebral structures. To analyze the cerebral blood supply, rheoencephalography, ultrasound of the vessels of the head, MRI of the vessels of the brain are performed.
Basilar migraine is an indication for the study of the cervical spine. Radiography of the spine, MRI or CT spine, ultrasound or CT angiography of the vertebral arteries is prescribed. The assessment of auditory function is carried out by a surdologist based on the results of audiometry and electrocochleography. The study of the vestibular analyzer includes video oculography, vestibulometry, caloric sampling, electronistagmography. Patients may have: latent spontaneous nystagmus, impaired vestibular reactivity, electrocochleographic sign of hydrops, audiometric data on sensorineural hearing loss.
It is necessary to differentiate basilar migraine with Meniere’s disease, cervical migraine (posterior sympathetic syndrome), vertebral artery syndrome, transient ischemic attack, retinal migraine. The difference between cervical migraine is the occurrence of focal neurological manifestations simultaneously with cephalgia, the absence of light and sound phobia, pronounced tonic tension of the cervical muscles, the presence of trigger points in the cervical spine. Meniere’s disease proceeds without headaches and visual disorders; the attack is accompanied by repeated nausea and vomiting, while with migraines they are noted only at the height of cephalgia. Retinal migraine, as a rule, begins with the formation of cattle, which then merge; it is not accompanied by other neurological manifestations typical of basilar migraine.
Treatment and prevention
Therapy of migraine of the basilar type is quite a difficult task. The use of nonsteroidal anti-inflammatory drugs (diclofenac, ketoprofen, ibuprofen, naproxen, etc.) usually does not stop paroxysm. Triptans (sumatriptan, naratriptan, eletriptan, etc.) are also not effective. Combined painkillers can only slightly alleviate the condition of patients during a migraine attack. A 10-minute inhalation of a gas mixture containing 90% oxygen and 10% carbon dioxide has a good effect. However, in ordinary life, this tool is not readily available. In some cases, basilar migraine can be stopped by taking prednisone. The effect of the drug is highest if it is taken in the first minutes of the appearance of the aura.
In the interparoxysmal period, patients are prescribed treatment aimed at strengthening the nervous system. These are mainly soothing pharmacological agents (tofizopam, alimemazine, amitriptyline), which reduce emotional lability and increase the patient’s resistance to stressful situations. It should be said that medical treatment in the field of mental health has only an auxiliary value. The main thing is a reassessment of values, a change in life attitudes and, accordingly, habitual psychological reactions. And this work should be done by the patient himself. It will result in calmer and more benevolent reactions to the events taking place, which will allow the patient to avoid the next migraine paroxysms.
With the development of vestibulocochlear syndrome and labyrinth hydrops, a course treatment is carried out with betaserk, which positively affects blood flow in the basilar artery, improves microcirculation in the labyrinth area and stabilizes endolymph pressure. It is possible to use electroson, reflexotherapy, massage of the cervical-collar zone, hydrotherapy, etc. procedures. Along with this, it is of great importance that the patient follows a number of preventive measures to avoid a new migraine attack. These include the exclusion of physical and mental overload, normalization of the daily routine, adequate amount and quality of sleep, hiking, proper nutrition.