Basilar Migraine (Migraine with Brainstem Aura) rare migraine subtype affecting the brainstem and posterior circulation territories. Characterized by aura symptoms such as visual disturbance, vertigo, tinnitus, dysarthria, or ataxia without motor weakness. Always consider serious differentials such as vertebral artery dissection, posterior circulation stroke, or CNS demyelination. Most common in adolescent girls and young women, but can occur across age groups.

⚡ Aetiology

Triggered by cortical spreading depression → wave of depolarisation disrupting brainstem and occipital cortex.
Involves trigeminovascular activation → neurogenic inflammation + vasodilation in posterior circulation.
Shares triggers with other migraine types:
- Stress 😥
- Hormonal changes (esp. menstruation) ♀️
- Certain foods (tyramine, nitrates, MSG) 🍷🥓
- Sleep disturbance 😴
- Bright lights or loud noise 💡🔊

📋 Diagnostic Criteria (ICHD-3)

At least two of the following reversible brainstem symptoms (no motor weakness):
- 👁 Visual disturbances (bilateral field defects, scotomas)
- 🗣 Dysarthria
- 🎢 Vertigo
- 👂 Tinnitus or hypoacusis
- 👓 Diplopia
- 🚶 Ataxia
- ✨ Bilateral paraesthesia
- 😴 Decreased consciousness
Aura usually lasts 5–60 mins, followed by occipital throbbing headache ± nausea/vomiting 🤢.
Must not be better accounted for by another diagnosis.

🔎 Clinical Features

Severe throbbing occipital headache, often after aura.
Aura without headache (acephalgic migraine) may occur.
Triggers include postural change, exertion, and stress.
Episodes may mimic TIA or seizure → careful history is essential.

🧾 Differential Diagnosis

🩸 Vertebral artery dissection (especially with neck trauma + unilateral signs)
🧠 Posterior circulation stroke
⚡ Epilepsy
🧩 Chiari malformation
🌐 Multiple sclerosis

🧪 Investigations

MRI brain – rule out stroke, demyelination, or dissection.
MRA/CTA – assess vertebrobasilar circulation and aneurysms.
EEG – if seizure is a differential.
Bloods – ESR/CRP, coagulation profile, metabolic screen.
LP – if infection or SAH suspected.

⚠️ Topiramate is teratogenic and subject to UK pregnancy-prevention restrictions. It is contraindicated in pregnancy for migraine prophylaxis and should not be used in women of childbearing potential unless the conditions of the Pregnancy Prevention Programme are fulfilled.

💊 Management

Acute therapy:
- ❌ Avoid triptans and ergotamines (risk of vasospasm in posterior circulation).
- ✔ Simple analgesia (ibuprofen, paracetamol).
- ✔ Antiemetics (e.g., metoclopramide) for nausea/vomiting.
Preventive therapy:
- Beta-blockers (propranolol) 💊
- Calcium channel blockers (verapamil) 🩺
- Topiramate / valproate if frequent or refractory
Lifestyle:
- Maintain regular sleep ⏰
- Avoid known triggers 🚫
- Encourage aerobic exercise 🏃‍♀️
Patient education:
- Explain benign but disabling nature.
- Highlight red flags → sudden severe neuro deficit, persistent confusion, unilateral weakness (→ urgent stroke pathway).

📈 Prognosis

Most improve with treatment + trigger avoidance.
Rare complication: posterior circulation stroke → necessitates careful monitoring.

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Headache - Basilar Migraine

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