Dear Dr. Roach: I am a healthy 64-year-old woman. My only medication is atenolol for blood pressure. I get the aura of migraines very often. The light flashing in my peripheral vision and then in front of my eyes always lasts between 30-45 minutes, no more. Then it is gone, leaving me with a tired, slightly dull pain in my eyes and head. I never get the horrible pain and nausea that normally are associated with a migraine headache. If I can, I go into a dark area, close my eyes for the time it is happening, and then resume normal activities when it’s over. These auras are happening more frequently.
I am writing to you because recently I have read articles in a medical newsletter warning that these symptoms could be a warning sign of stroke or heart attack. I showed the articles to my cardiologist and ophthalmologist. Both said they had never heard of such a thing.
Do you know anything about the migraine aura without the headache? Should I ignore these auras and not worry, or try to find a doctor who can test to see if it’s due to something more serious?
At one time in my life, I was told they were caused by stress or hormones.
Dear J.D.: It sounds to me most likely that you have migraine aura without headache, also called acephalic migraine or migraine equivalent. The features that support this include the time course of less than an hour and the relief from lying in a dark room. However, it can be difficult to distinguish a migraine aura from a transient ischemic attack, or TIA, which is indeed similar to, and a warning sign of, a stroke. Migraine auras tend to develop over five minutes or so, whereas the vision changes and numbness of a TIA start abruptly.
I would not recommend that you ignore these auras, as the situation is complex. Some conditions that predispose a person to stroke can cause migraines, such as arteriovenous malformations. There is probably an increased risk for stroke in women who have migraine with aura. This means that it is worth having a discussion with a neurologist with expertise in migraine and stroke. I also would recommend that you discuss with your cardiologist what you can do to reduce your risk of stroke (they are the same risk factors as for heart attack). This means monitoring cholesterol, careful blood pressure control, not smoking, maintaining a proper diet and getting regular exercise, and possibly taking aspirin. It is particularly important for people who have migraine with aura to quit smoking.
Finally, some experts recommend against taking a beta blocker like metoprolol in people over 60 with migraine, as they do not reduce stroke risk as much as other treatments for high blood pressure, such as diuretics or ACE inhibitors.
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