Course of definite persistent aura

Jane10 [subject #23], Persistent aura, 2006. © 2006 Jane10 [more]

The clinical course of persistent aura was studied in 60 participants in Sofia Greene's internet survey who were diagnosed as having definite persistent aura without infarction according to the diagnostic criteria used in this study. Persistent aura can occur in all age groups, although it is more common among subjects aged greater than 18 years. In 13,3 % of cases, persistent aura symptoms have existed for as long as the subject can remember, suggesting a very early onset before the age of 3-7 which is eventually obscured by childhood amnesia. Trigger factors of persistent aura reported by 35,0 % of subjects include psychological stress or physical stress from somatic illness, whereas in the majority of cases no precipitating factors were identified. In two thirds (66,7 %), the onset of persistent aura was without associated headache. In 15,0 % of cases, it occurred at night or over night as a complication of nocturnal migraine. The continuous variety (95,0 %) prevails over the repetitive variety (5,0 %) of persistent aura in frequency with a ratio of 19 : 1. Some subjects display features of both varieties of the given migraine complication, suggesting that they are basically the same condition. Over half of the subjects (60,0 %) had sustained multiple episodes of persistent aura without infarction, a hitherto undescribed clinical scenario of persistent aura that contributes to the increasing evidence that migraine should be conceptualized as a chronic-episodic and sometimes chronic progressive disease. Only 24,1 % of all 166 episodes from 60 subjects showed complete remission, 21,7 % partial remission, 51,2 % stable disease and 3,0 % progressive disease. Most subjects with multiple episodes of persistent aura reported ever-worsening neurological symptoms across successive episodes of the given migraine complication. The duration of these episodes with persistent aura symptoms ranges from one week to 39 years with a mean of 4,8 years, giving testimony of the condition's tendency towards chronification.

The results obtained in this study change generally accepted views of classic migraine. In some subjects, migraine with aura may be a more serious disorder (Wang et al., 2008), not just a subjective light show that may or may not be followed by a headache. With such shift in conceptualization of persistent aura as a chronic-episodic and sometimes chronic progressive disease, the goals of treatment may also change. Preventing disease progression in persistent migraine aura without infarction has to be added to traditional clinical goals in migraine therapy (for example by modification of risk factors, preventive therapy, or early pharmaceutical treatment of episodes of persistent aura). We appreciate that the present results may raise concerns (Welch, 2005) among sufferers from persistent aura without infarction and maybe among migraine sufferers in general. However, it must be emphasized that the absolute risk of sustaining persistent aura without infarction is very low. The underlying pathomechanisms of brain damage in persistent migraine aura without infarction (characterised by subjects who participated in this study as neurons "getting injured by migraine events", "tickled neurons... having received a bruise from particularly bad episodes of migraine", "the chemicals released by our brains during our migraine attacks... messing up those neurons", "some kind of trauma that needs to heal") have not yet been established. As judged from the few available neuroimaging studies of patients with long-lasting visual auras, cortical spreading depression and localised brain oligaemia are likely to contribute to the pathogenetic mechanisms responsible for the persistent neurological symptoms (Agostini and Aliprandi, 2006). Although prevention or early abortion of episodes of persistent aura seem to be logical steps to reduce the risk of chronification, such interventions have to be evaluated in large-scale studies, before an evidence-based treatment-advice to clinicians and patients can be given.

References

Agostini E, Aliprandi A. Complications of migraine with aura. Neurol Sci 2006; 27: S91-S95.
Wang YF, Fuh JL, Chen WT, Wang SJ. The visual aura rating scale as an outcome predictor for persistent visual aura without infarction. Cephalalgia. 2008 Aug 22. [Epub ahead of print]
Welch KMA. Uncertainties and concerns in viewing migraine as a progressive disorder; an analysis of clinical and imaging studies. Cephalalgia 2005; 25: 1189-1205.

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