Other patients complain instead of blurred or shimmering or cloudy vision, as though they were looking through thick or smoked glass or the wavy distortions produced by heat rising from asphalt. These luminous hallucinations move slowly across the visual field for several minutes and may leave an island of visual loss in their wake (scotoma); the latter is usually homonymous (involving corresponding parts of the field of vision of each eye), pointing to its origin in the visual cortex. Patients often attribute these visual symptoms to one eye rather than to parts of both fields. Ophthalmologic abnormalities of retinal and optic nerve vessels have been described in some cases but are not typical.
Other neurologic symptoms, less common than visual ones, include numbness and tingling of the lips, face, and hand (on one or both sides); slight confusion of thinking; weakness of an arm or leg; mild aphasia or dysarthria, dizziness, and uncertainty of gait or drowsiness. Only one or a few neurologic phenomena are present in any given patient and they tend to occur in more or less the same combination in each attack. If weakness or paresthetic numbness spreads from one part of the body to another, or if one neurologic symptom follows another, this occurs relatively slowly over a period of minutes (not over seconds, as in a seizure, or virtually simultaneously in all affected parts as in a transient ischemic attack).
The visual or neurologic symptoms usually last for less than 30 min, sometimes longer. As they recede, a unilateral dull pain develops of slowly increasing intensity that progresses to a throbbing headache (usually but not always on the side of the cerebral disturbance). At the peak of the pain, within minutes to an hour, the patient may be forced to lie down and to shun light (photophobia) and noise (phonophobia). Light is irritating and may be painful to the globes, or it is perceived as overly bright (dazzle) and strong odors are disagreeable. Nausea and, less often, vomiting may occur. The headache lasts for hours and sometimes for a day or even longer and is often the most disabling feature of the illness. The temporal scalp vessels may be tender and the headache is worsened by strain or jarring of the body or head. Pressure on the scalp vessels or carotid artery may momentarily reduce the pain and releasing pressure accentuates it.
Between attacks, the migrainous patient is normal. In the past, it was believed that a migrainous personality existed, characterized by tenseness, rigidity of attitudes and thinking, meticulousness, and perfectionism. Further analyses, however, have not established a particular personality type in the migraineur. A relationship of migraine to epilepsy in general is also tenuous; however, the incidence of seizures is slightly higher in migrainous patients and their relatives than in the general population, and there are syndromes that encompass both disorders. In surveys, affective disorders, particularly depressive and anxiety disorders, are more common in patients with migraine than would be expected by chance.
Some patients note that their attacks of migraine tend to occur during the “let-down period,” after many days of hard work or tension. There is an overrepresentation of motion sickness or a vague instability of vision or accommodation, sensitivity to striped patterns, fainting, and of fleeting sensory symptoms on one side of the body in migraineurs. Moreover, as appreciated by Graham, migraine has a lifetime profile and is a familial disease that includes some or many of the following: colic in infancy, motion sickness, episodic abdominal pain, fainting, alcohol sensitivity, exercise-induced headaches, “sinus headaches,” “tension headaches,” and menstrual headaches. These are fairly dependable markers of the disease, and their absence in the patient or family members should at least cause the consideration of alternative explanations for cranial pain.
Alternative Patterns of Migraine