Assessing and Treating Complex Migraine
As mentioned, a diagnosis of FHM requires that the patient have at least one first-or second-degree relative who has also had attacks fulfilling these criteria. Lastly, a diagnosis requires that these symptoms not attributed to another disorder. Since the disorder was first described in 1920 by Clark,4 there have been more than 150 families reported in the literature. There is also a sporadic form of this migraine disorder known as sporadic hemiplegic migraine (SHM),5 which shares similar diagnostic criteria with FHM. With SHM, the patient must have no first- or second-degree relative who has migraine with aura including motor weakness.
Complex/atypical migraine can be very frightening to the patients who experience it.
When a patient has a first episode of a hemiplegic migraine, even if there may be a family history of the same, but especially if family history is not knowna full neurological evaluation should be done to rule out a cerebral vascular accident (CVA). Note that the FHM diagnostic criteria indicate a gradual onset of symptoms, while during a CVA or transient ischemic attack, the symptoms are sudden.
Another form of complex migraine, basilar-type migraine (also known as “Bickerstaff Migraine”), appears to go beyond just basilar artery involvement to include involvement of the posterior fossa. Echoing the prevalence seen across migraine types, basilar-type migraine occurs most often in young women. Findings suggest transient focal reduction of cerebral blood flow during the aura phase of this entity, but it has not been entirely determined if the vascular changes are the cause or the consequence of neuronal dysfunction. The diagnostic criteria for basilar-type migraine include:3
A. At least two attacks fulfilling criteria B through E
B. Fully reversible visual, and/or sensory, and/or speech aura but no motor weakness
C. Two or more fully reversible aura symptoms of the following types:
d. Decreased hearing (hypacusia)
e. Double vision (diplopia)
g. Decreased level of consciousness
h. Simultaneous bilateral visual symptoms in both the temporal and nasal field of both eyes
i. Simultaneous bilateral paresthesias
D. At least one of the following:
a. At least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes
b. Each aura symptom lasts ≥5 and ≤60 minutes
E. Headache lasting 4-72 hours that has two or more of the following characteristics: unilateral location, pulsating quality, moderate to severe pain intensity, and/or aggravation by or causing avoidance of routine physical activity. During the headache attack, the patient must experience at least one of the following symptoms: nausea and/or vomiting, photophobia and phonophobia. Headache attacks begin during the aura or follow aura within 60 minutes.
F. Not attributed to another disorder.
Basilar-type migraine is the only headache entity associated with syncope. Finally, to mention two other complex forms of migraine, there is indeed migrainous infarction as well as migraine-triggered epilepsy (or seizure) and retinal migraine, but space prohibits a more thorough discussion.