Basilar migraines are rather rare and although they are extremely painful, they are also fairly short. Generally, a basilar migraine will last about an hour, but more severe attacks may last several hours. If you have basilar migraines, this guide will help you better understand your condition.
Axon Optics talked to Richard P. Kraig, Ph.D., M.D. of the Department of Neurology at the University of Chicago Medical Center and he provided some valuable insight into the condition. “Basilar migraine is relatively rare and my practice is consistent with literature,” says Dr. Kraig. “The literature shows about 10% of patients have migraine with aura present with basilar type and that is about what I see in my practice.”
The basilar migraine goes by many names. This rare condition was once called basilar type migraine or basilar artery migraine because it was believed that the basilar artery was where the attack originated. In 1961, Bickerstaff coined the term in a published report on his belief that the migraine resulted from a spasm of the basilar artery or due to it narrowing temporarily. For many years, this was the standard that the medical community accepted.
In 2016, the Axon Optics published its Guide to Types of Headaches. In it, the term “basilar migraine” and all of its other associated terms were changed to Migraine with Brainstem Aura. The description is:
A rare migraine that originates at the brainstem (lower part of the brain). It initially presents with an aura which can include symptoms like double vision, nausea, lack of coordination, and tingling in the hands and feet. The aura may last a few minutes to nearly an hour before the onset of pain which typically begins on one side of the head but can gradually spread to other areas of the head.
Some arguments have been raised that the headache does not necessarily originate in the basilar artery, but it seems that some doctors do not agree.
It is now widely believed that the basilar migraine originates in the nerves surrounding the artery, not the blood vessels themselves. In other words, it generally isn’t vascular. Sometimes, though, a problem or defect such as an aneurism can cause basilar type headaches. That presents a challenge in diagnosis because the symptoms of basilar migraines very closely mimic symptoms of other conditions.
Signs and Symptoms of Basilar Migraines
One of the biggest problems with this type of migraine is the symptoms of the aura and migraine are similar to those of several serious conditions, including:
- Space occupying lesion of the brain (malignant tumor, hematoma, abscess)
- Hemiplegic migraine
- Vertebrobasilar disease (a narrowing or blood clot in the arteries that supply blood to the brainstem)
- Brainstem arteriovenous malformation, AVM (a congenital defect involving abnormal veins and arteries that are tangled and are lacking the capillaries between them – the result is higher blood pressure in those veins which could result in the vein rupturing and bleeding in the brain)
Recognizing the symptoms is the first step in managing basilar migraines as well as your life around it.
Typical Symptoms – Basilar migraines actually occur in two parts, the aura and the actual migraine. The aura symptoms can last just a few minutes or as long as an hour. These symptoms include:
- Difficulty speaking or slurred speech (dysarthria)
- Tingling in the body (especially the hands and feet)
- Light sensitivity
- Temporary blindness
- Visual disturbances (both eyes)
- Loss of consciousness
- Cold feet or hands
- Loss of balance or lack of coordination (ataxia)
- Dizziness or vertigo (feeling that you are spinning or the world around you is spinning)
- Difficulty hearing (hypacusis)
- Ears ringing (tinnitus)
- Double vision (diplopia)
- Graying of vision
Many of the associated symptoms may be accompanied by anxiety and hyperventilation which can make diagnosis difficult. When the migraine begins, it is usually marked by a pulsating or throbbing pain that is usually located in the back of your head or it can be on one or both sides.
When to Call the Doctor – Most migraines are not dangerous or life threatening, even though the pain and symptoms may be debilitating. Sometimes the symptoms you experience may warrant a trip to the ER, or at least a conversation with your doctor. Make sure you bring your migraine journal with you which documents your attacks, symptoms, and what treatments you used.
Talk to your doctor if you experience any of these symptoms or issues:
- If you start having any new or unusual symptoms that you’ve not had before
- If the pattern of your migraines changes
- If your headache or migraine suddenly feels different
- If you have a chronic illness like kidney, heart, or liver disease
- If you are pregnant
- If you have an immune deficiency disorder
If you experience any of these symptoms, don’t wait till your next appointment; call your doctor immediately.
If you suddenly experience symptoms (that are not a part of your established, diagnosed migraine pattern) that include headache with:
- Tunnel vision
- Stiffness in the neck
- Double vision
- Difficulty speaking
- Mental confusion
- Headache that occurs after a head injury – especially if it worsens in intensity or symptoms
- A “thunderclap” headache – severe and abrupt
- A chronic headache that worsens after exertion, coughing, sudden movements, or straining
- If you are over 50 and have new headache pain
- Stroke from migraine is extremely rare, but it does occur so be aware of the signs of a stroke
You want to rule out other conditions that may be present or could be causing your migraine so getting a diagnosis is essential.
Dr. Kraig says, “Symptoms of basilar migraine are often a concern for patients. My advice is to have a neurologist see these patients as soon as possible – to make a definitive diagnosis of basilar migraine and to be sure, as well as assure, patients that other neurological problems are not involved. That said, stroke from a basilar migraine is very rare.”
Causes of Basilar Migraines
When a basilar migraine is not accompanied by an associated or comorbid condition, its causes are often much the same as any other type of migraine. These may include:
- Certain foods
- Hormonal changes (females)
- Lack of sleep
- Bright or flickering lights
- Over exertion
- Loud music or noise
- Poor posture
- Additives in food, including nitrates, MSG, etc.
- Strong smells
The exact cause of basilar migraines is still not fully understood. Researchers believe certain parts of the brain (such as the occipital lobe and brainstem) that do not get adequate blood flow or the blood flow to the brain is altered can be a contributing factor. Nerve abnormalities are also cited as a possible cause. In some very rare cases, scientists believe that basilar migraine is familial, meaning that there is a genetic component that can be passed from parent to child.
Trauma or injury to the cervical spine (the neck), such as whiplash, can cause migraines. However, in some cases even injuries to the thoracic (mid back) or lumbar (lower back) can also cause migraines. Head injuries, concussion, and traumatic brain injuries may trigger migraines as well. In many of these cases, the problem is structural with pressure on the nerves or inflammation in that area that triggers the headaches.
Diagnosing Basilar Migraine
An individual who experiences any of the symptoms of basilar migraine should see their doctor. Getting a diagnosis can help direct treatment, but it can also rule out any underlying causes of the condition.
The International Classification of Headache Disorders, 3rd edition, provides detailed diagnostic criteria for basilar migraine:
A. At least two attacks fulfilling criteria B-D
B. Aura consisting of visual, sensory and/or speech/ language symptoms, each fully reversible, but no motor or retinal symptoms
C. At least two of the following brainstem symptoms:
- decreased level of consciousness
D. At least two of the following four characteristics:
- at least one aura symptom spreads gradually over 5 minutes, and/or two or more symptoms occur in succession
- each individual aura symptom lasts 5-60 minutes
- at least one aura symptom is unilateral
- the aura is accompanied, or followed within 60 minutes, by headache E. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded.
It is recommended that a headache specialist or neurologist make the diagnosis. Part of the reason for this is they are qualified to identify any neurological problems or conditions that could be causing the migraines. They will also have to rule out other conditions that are more serious, including:
- Vertebrobasilar disease
- Meniere’s disease
- Brain lesions
- Vestibular disorder
- Brainstem arteriovenous malformation
Basilar migraine is often mistaken for hemiplegic migraine. The symptoms of these two conditions are every similar. The primary difference is the motor weakness that is present during a hemiplegic migraine.
When forming a diagnosis, the doctor will talk to the patient about their headaches as well as any family illnesses or conditions. Diagnostic tools they may use include CT scan, MRI, and lumbar puncture. These will help rule out other conditions or issues that may contribute to the migraines.
Treatment for Basilar Migraines
There is no magic bullet for treating basilar migraines and for some pain management is extremely difficult, if not impossible. In most cases, treatment includes a combination of medication, lifestyle changes, dietary changes, and even surgery. Many migraine patients have found relief with chiropractic care, yoga, and acupuncture.
Medication for Basilar Migraines – Certain medications may be prescribed for basilar migraineurs, but the most popular tend to be over the counter products like NSAIDs (ibuprofen), Acetaminophen, and naproxen, or prescriptions for stronger doses. Nausea medications may also be recommended or prescribed. For the most part, the treatment focuses more on the management of symptoms than it does stopping the migraine.
Many of the medications used to treat other types of migraines can also be prescribed. Some of the more commonly prescribed medications that are effective in treating the symptoms of basilar migraine include:
While these medications may help ease the pain of a basilar migraine, they often have side effects that can cause discomfort or even be dangerous. They can also be highly addictive. It is important to closely follow your doctor’s instructions when taking these medications.
Because nausea is a very common symptom of basilar migraine, medication may be prescribed to address that, including:
Preventing Basilar Migraines – Most migraine treatment is focused on prevention of an attack. Once a migraine has started, it is difficult to stop – and it becomes even more difficult as the attack progresses. This is compounded by the risks and problems associated with prescription migraine treatment. Opioids or medications containing butalbital should not be considered as first-line treatment for basilar migraines (or any other for that matter) due to their addictive properties and side effects. Frequent or prolonged use of over the counter medications should also be discourage. Overusing OTC medications such as NSAIDs can lead to rebound headaches.
There are several medications that can help prevent migraines or make them less severe:
- Beta blockers
- Calcium channel blockers
Other treatments that may be used to prevent migraines include those that:
- Treat seizures
- Lower your blood pressure
- Treat depression
- Botox injections (about every 3 months)
- Transcutaneous supraorbital nerve stimulation (t-SNS)
Management of Environmental or Lifestyle Triggers – Learning to manage lifestyle or environmental migraine triggers can be a big step for many migraineurs. By giving them some control over a seemingly out of control situation, they can take empowering, proactive steps in their own health management.
It is important to keep a headache journal so you can track your symptoms and patterns of your migraines. You can then use the information to identify migraine triggers. Once you have an idea of what is causing your migraines, you can take steps to manage that within your own environment. For instance, if bright lights trigger your headache, you can choose window coverings that either (depending on your degree of sensitivity) block the light or filter it so it is softer.
Diet, regular exercise, good quality sleep, and stress management are all vital to not only decreasing the incidence or severity of your migraines, but for your overall health as well. A consistent schedule that you can establish for most days can help as well. Skipping meals is a well-known migraine trigger, so setting regular meal times is essential.
Some women find that estrogen is a migraine trigger. If that is the case for you, or if you believe it worsens your headaches, talk to your doctor about reducing or avoiding medications that contain the hormone. This can include hormone replacement therapy and birth control pills.
Learning to cope (LTC) is not necessarily a new migraine management strategy, but recent research indicates it can be very effective in migraine prevention. The process involves gradual exposure to migraine triggers in an effort to desensitize the body and brain against them. Cognitive behavioral therapy may also be used along with LTC.
Many migraineurs are looking for more natural ways to prevent and manage their migraines. There are quite a few options, but it is important to remember that what works for one person may not work for another. As with any migraine treatment, you have to find what works for you. Everyone is different and so are their migraines.
Magnesium – Several studies show that magnesium is often quite effective in reducing migraine frequency, especially in people who have low magnesium levels. People who may have low levels of magnesium include those who diuretics (for blood pressure or other reasons) and people with heart disease or diabetes. Alcoholism has also been associated with low magnesium levels. The recommended dose of magnesium is between 200 and 600 mg a day.
Lavender and peppermint essential oils – Many people are turning to aromatherapy and using essential oils for migraines with great success.
Lavender oil is very soothing, calming the mood and acting as a sedative to relieve stress and anxiety. Inhaling lavender can begin decreasing your headache in as little as 15 minutes.
Peppermint oil has a stimulating aroma that helps you breathe easier. When applied to the skin, it increases blood flow and can calm contractions of the muscles.
When using essential oil as a topical application, you may want to use a carrier oil like jojoba or almond oil to soften the aroma and decrease your skin’s sensitivity. Using coconut oil as a carrier oil provides additional health benefits such as balancing your hormones. You should always test essential oils on your skin (the wrist area is a good test spot) before using to make sure you aren’t sensitive to it. When using it to relieve migraines apply it to your forehead, temples, and back of the neck.
Butterbur and Feverfew – Butterbur is an herb that acts as a beta blocker and has anti-inflammatory properties making it good for reducing the effects of migraine triggers. The recommended dose for migraine treatment and prevention is 75 mg twice a day.
Studies show that feverfew is not only effective in reducing migraine frequency, it also helps with the associated symptoms which include nausea, light sensitivity, noise sensitivity, vomiting, and pain. It can be taken as a capsule, tablet, or liquid extract. The recommended dose for migraine treatment is 50 to 100 milligrams.
Chiropractic – Spinal manipulation has long been touted as an effective treatment for migraines and several studies support those assertions. In the case of basilar migraines, chiropractic care may be particularly effective since the condition seems to be rooted in inflamed nerves and neural pathways.
What You Should Know About Basilar Migraines
If you are a person who has basilar migraines or if you are a friend, family member, or boss of someone with the condition, there are a few things you need to know.
As a Patient – First of all, your condition is not your fault. Sometimes even the best preventative measures simply will not stop a migraine attack. If you are undiagnosed, but are having symptoms that seem to indicate you may have basilar migraines, there are a couple of things you need to do.
- See a headache specialist and get a diagnosis. Basilar type migraines are quite rare so a general practitioner or doctor who does not specialize in headaches may not fully understand this complex condition and give you a diagnosis as well as a good treatment plan.
- If any of your symptoms are alarming or resemble a stroke, don’t wait to see if it passes, call your doctor. Even if the symptoms pass you should still talk to your doctor about them. Your health is too important to brush off, thinking you are overreacting. You know your body better than anyone and if you feel like something is wrong then follow up on it.
- If your migraines are affecting your job, you can request reasonable accommodations. This could mean having your own office so that you can lower the lights or control the smells in your work environment. It could mean you are allowed a more flexible schedule so you can go to doctor appointments or manage your attacks. You may be able to use noise cancelling headphones if noise is a problem, or special computer filters to reduce the flickering on your screen. The Americans with Disabilities Act (ADA) does not name specific disabilities that are covered, but provides a definition:
a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment.
Don’t be afraid to be completely honest with your doctor. Tell him or her how your migraines affect your quality of life. Keeping a migraine journal can help you keep track of how many migraines you have, the symptoms you experience, and what treatments worked for you. This will allow you and your doctor to identify any patterns and find the best treatment strategy for you.
As a Friend or Family Member – It can be very frustrating, even emotionally painful, to see someone you care about who is struggling with such a debilitating condition. The best thing you can do for them is:
- Educate yourself on basilar migraine. Reading this Basilar Migraine Guide is a great start! You may also find our reference links helpful as well.
- Find out how their basilar migraine affects them. While migraines may share certain symptoms from person to person, everyone is different and everyone experiences their migraines in a very different and personal way. Talk to them and ask about their migraines, the pain, the symptoms, the aura, but also ask how it impacts their life.
- Ask what you can do to help. This is something that people with chronic conditions don’t often hear. Maybe you can be on standby to watch their children when they have an attack. When they come to your house it may be easier for them if you draw the blinds or make it a little cooler or refrain from using air freshener. That goes a long way in showing that you truly care.
Talking to Your Doctor about Basilar Migraines
Basilar migraines are very rare and you should be seen by a headache specialist to get a diagnosis and treatment. At your appointment, make sure you bring your headache journal. Jot down any questions beforehand so that you won’t forget anything. When talking with your doctor, be honest even if some questions are uncomfortable.
These are some common questions that you may want to ask:
- What are my treatment options?
- What medications are available to me?
- How soon can I expect to see results from the medication or treatment?
- What are the side effects of the medication or treatment?
- What symptoms are considered normal?
- What constitutes an emergency, or abnormal symptoms and when should I call you?
You may also discuss your current medication and how well it works, strategies for taking your medication when you are experiencing nausea and vomiting, and any side effects that your current medication has that are bothersome to you.
The Future for Patients with Basilar Migraines
When we asked Dr. Kirby about migraine medications and treatments currently in development, he shared some exciting news. “There are two classes of new treatments that I can mention, he said. “The ﬁrst are the new CGRP (calcitonin-gene receptor antagonists). Several varieties are now progressing through the regulatory process and the data shows they can be eﬀective.”
He continued, “The second, which is at a much earlier stage, is a new agent we have proposed – nasal administration of insulin-like growth factor-1 (IGF-1). It is a naturally occurring agent that can be released in the body when we exercise. When given via a nasal administration route, it markedly prevents migraine in animal models. We have launched a new company (Seurat Therapeutics, Inc; see Crain’s Business) to bring IGF-1 through the clinical development stage and to patients.”
This could be very good news for individuals who suffer from basilar migraines – or any type of migraine for that matter.
Resources for Basilar Migraine Patients
There are many resources available for people with basilar migraines. These are some of our favorites where you can communicate with others who have the condition and get support:
- Patients Like Me
- MD Junction
- Basilar Artery Migraine Support (Facebook Group)
- Job Accommodation Network (JAN)
A special thank you to Richard P. Kraig, Ph.D., M.D. for his invaluable contributions to this guide.
Richard P. Kraig, Ph.D., M.D.
William D. Mabie Professor in the Neurosciences
Departments of Neurology and
Neurobiology, Pharmacology & Physiology
Cerebrovascular Disease and Aging Laboratories
The University of Chicago Medical Center
Department of Neurology; MC2030
5841 South Maryland Avenue, Chicago, IL 60637-1470