The initial attack is not easily identifiable as a benign condition and various forms of imaging are reasonably performed in order to exclude basilar artery and upper brainstem disease. The issue of risk of causing stroke from the administration of intrarterial contrast is often raised and is unresolved. With recurrent similar attacks, the diagnosis becomes clearer and the use of imaging becomes less necessary.
Episodes of cyclic vomiting or periodic recurrent abdominal pain have been linked to migraine as a result of the frequent co-occurrence of these symptoms with headache or typical migraine at other times. Pallor, lethargy, and mild headache are common. This episodic disorder seems to be a problem almost exclusively of children. The results of diagnostic investigation are normal but one cannot be faulted for pursuing some form of testing with the initial occurrence of the syndrome.
Dizziness is certainly a common accompaniment of migraine and its auras. A less certain syndrome associates episodic vertigo with migraine, mainly in children but also in some adults who are known migraineurs. Patients report varying degrees and types of dizziness, are disturbed by highly patterned or crowded visual environments, and can be disabled by imbalance but the examination during a symptomatic period is most often normal. Many of these features accord with anxiety but the episodic occurrence of symptoms and interspersed attacks of migraine make the connection plausible. Bedside vestibular testing is normal, however, a proportion of patients is found to have minor central or peripheral deficits on more elaborate laboratory testing (see Chap. 14). Similarly, a tenuous relationship between an episodic vertigo syndrome and migraine in children, as described by Basser, is discussed in Chap. 14.
Ophthalmoplegic migraine in the current terminology of the International Headache Society is “recurrent painful ophthalmoplegic neuropathy” rather than migraine but it is most conveniently described here. It consists of a recurrent unilateral headaches associated with weakness of extraocular muscles. A transient third-nerve palsy with ptosis, with or without involvement of the pupil, is the usual picture; rarely, the sixth nerve is affected. This disorder almost exclusively occurs in children. As a general rule, the diagnosis should not be made in adults unless there had been recurrent bouts in childhood. The ocular paresis often outlasts the headache by days or weeks; after many attacks, a slight mydriasis and some degree of ophthalmoparesis may remain permanently. We and others have encountered instances of gadolinium enhancement of the proximal, cisternal portion of the third nerve during and after an attack. However, in adults the syndrome of headache, unilateral ophthalmoparesis, and loss of vision may have more serious causes, including temporal (cranial) arteritis.
In another entity that is more clearly allied with migraine than the ophthalmoplegic variety above, retinal, or ocular migraine, there are purely monocular visual symptoms of scintillations or scotoma (in contrast to the often reported unilateral but actually asymmetric homonymous nature of these symptoms). The visual loss can be quite severe or complete but is transient and recovers fully. Often in our experience, there is no headache but if one is present, it is of the typical migraine type, not ocular pain. In some cases of uniocular visual disturbance with scotoma, fortuitous examination during an attack may reveal attenuation of the retinal arterioles as noted by Berger and colleagues. Most often, there are no funduscopic changes. Either the retinal or the ciliary circulation is probably involved. Knowledge of this syndrome in a young healthy person may prevent excessive evaluation and unnecessary treatment, although antiphospholipid antibody syndrome and other hypercoagulable states are considerations. In older persons, carotid disease and giant cell arteritis merit investigation.
In the disorder hemiplegic migraine, a condition mostly of infants and children (rarely adults), there are episodes of unilateral paralysis that may long outlast the headache. Other unusual clinical features have been unilateral massive brain swelling with recovery, putatively in some cases triggered by minor head injury.