What you need to know about silent migraine

Silent migraine, also known as acephalgic migraine, is a type of migraine that occurs without typical head pain. Instead of a throbbing head sensation, silent migraine primarily manifests through aura symptoms. 

Aura symptoms are temporary changes that can occur before or during a migraine attack. They can cause visual disturbances, such as flashing lights or blind spots, as well as other neurological symptoms.

What are the symptoms of silent migraine?

Symptoms of silent migraine may include:

• Aura: Before silent migraine occurs, you may experience aura, which refers to sensory disturbances before or during a migraine episode. These may include visual disturbances such as seeing:
  • flashing lights
  • blind spots
  • zigzag lines
• Sensory disruptions: Silent migraine can cause tingling or numbness in your face, hands, or other body parts. Additionally, you may experience sensitivity to light and sound, leading to discomfort or avoidance of bright lights and loud noises.
• Cognitive issues: Cognitive impairments can occur during silent migraine, affecting concentration and decision-making abilities. Some people may also experience confusion or have difficulty finding the right words.
• Gastrointestinal symptoms: Despite the absence of head pain, silent migraine can still cause nausea and vomiting, similar to classic migraine.
• Mood changes: Some people may experience mood changes, such as irritability.
• Fatigue or weakness: A silent migraine may leave you feeling drained, tired, or physically weak.

It’s important to know that abdominal migraine is different than silent migraine. This is a type of migraine that causes nausea and vomiting without a headache and is most common in young children and teenagers. It is not associated with aura.

What can cause silent migraine?

While the exact causes of silent migraine, like other types of migraine, are unknown, the risk factors for silent migraine and classic migraine are the same, with one exception — older adults are more likely to experience silent migraine than younger adults.

Researchers believe that several factors can lead to the development of silent migraine, including:

• Genetic predisposition: A 2022 review study notes specific genetic variations associated with an increased risk of migraine, indicating that the condition may run in families.
• Hormonal fluctuations: Hormonal changes, particularly in women, have been linked to migraine, including silent migraine. Varying estrogen levels during menstruation, pregnancy, or menopause, have been identified as potential triggers for migraine.
• Stress and emotional factors: Emotional stress, anxiety, and tension have long been recognized as triggers for migraine, including silent migraine.
• Environmental triggers: Environmental factors can trigger silent migraine. These include: 
  • strong smells
  • bright lights
  • loud noises
  • weather changes
• Sleep disturbances: Irregular sleep patterns, insufficient sleep, or disrupted sleep are associated with an increased risk of migraine, including silent migraine. 

How is silent migraine diagnosed?

A doctor will usually take a thorough medical history to diagnose silent migraine. They may ask about the following:

• what symptoms you have been experiencing
• frequency of migraine attacks
• duration of migraine attacks
• if you are experiencing any aura symptoms

They might also ask about your family history of migraine or other neurological conditions.

They may conduct a thorough physical examination, including a neurological assessment, to assess your overall health and rule out any other underlying conditions causing the symptoms.

Migraine criteria

To confirm the diagnosis, a doctor may use the International Classification of Headache Disorders (ICHD) criteria, which includes guidelines for diagnosing different types of migraine, including silent migraine.

To receive a diagnosis of silent migraine, also known as a typical aura without headache, you should be experiencing a minimum of two attacks fulfilling the below criteria:

• at least one of the following aura symptoms:
  • visual
  • sensory
  • speech and/or language
  • motor
  • brainstem
  • retinal
• at least three of the following characteristics:
  • a minimum of one aura symptom that spreads slowly over the span of 5 minutes or more
  • two or more aura symptoms that occur straight after the other
  • each aura symptom must last between 5 and 60 minutes
  • a minimum of one aura symptom that affects only one side of the body
  • a minimum of one aura symptom that is positive, such as flash hallucinations
• you should not experience a headache within 60 minutes of the aura
• your symptoms should also not be able to better fit into another ICHD-3 diagnosis

Migraine testing

Although no specific test confirms a silent migraine, your doctor may order certain tests to rule out other conditions, such as stroke or a transient ischaemic attack (temporary symptoms that mirror stroke), which can mimic migraine symptoms.

These may include:

• blood tests
• imaging studies, such as an MRI or CT scan
• an electroencephalogram (EEG) to assess brain activity

Treatment options

Managing a silent migraine can involve a combination of medications and lifestyle measures. 

Medications

While no medications are specifically approved for treating or preventing silent migraine, the medications for migraine treatment are also commonly used for silent migraine.

Some commonly prescribed medications for migraine include:

• Triptans: A doctor may prescribe triptans to alleviate aura symptoms and prevent the progression of silent migraine. These medications work by constricting blood vessels in the brain and reducing inflammation. Examples include sumatriptan (Imitrex) and zolmitriptan (Zomig).
• Preventive medications: A doctor may prescribe certain medications to prevent silent migraine. These medications also help reduce the frequency and intensity of aura symptoms. Examples include:
  • nortriptyline (Pamelor)
  • venlafaxine (Effexor XR)
  • topiramate (Topamax)
• Valproic acid: Valproic acid is sometimes prescribed as a preventive medication for silent migraine. For some people, it may effectively reduce the frequency and severity of migraine attacks and aura symptoms.
• Dihydroergotamine: Dihydroergotamine (Migranal) is an effective option for acute treatment and silent migraine prevention. It constricts blood vessels and reduces inflammation in the brain, relieving aura symptoms.
• Gepants: Gepant medications should be taken at the beginning of an attack and can help treat symptoms such as nausea and pain. Examples include:
  • rimegepant (Nurtec)
  • ubrogepant (Ubrelvy)
  • atogepant (Quilipta)

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Lifestyle measures

Lifestyle measures for treating migraine can include:

• Stress management: Stress is a common trigger for migraine, including silent migraine. Stress management techniques like deep breathing exercises and meditation can help reduce the frequency and severity of episodes.
• Sleep hygiene: Ensuring a regular sleep routine and adequate sleep duration is essential for managing silent migraine.
• Dietary considerations: Certain foods and beverages, such as processed foods, caffeine, and alcohol, may trigger migraine. Keeping a food diary and identifying trigger foods can help you make dietary adjustments to prevent silent migraine.
• Regular exercise: Regular physical activity can help reduce the frequency and intensity of migraine. Aim for moderate exercise, such as walking, swimming, or cycling, for at least 30 minutes most days a week.

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When should you speak with a doctor?

Consider speaking with a doctor if you have the following: 

• visual disturbances 
• sensory disruptions 
• cognitive impairments 
• dizziness 
• nausea without a clear explanation

A doctor can help diagnose your condition, rule out other possible causes, and provide appropriate treatment options to manage and alleviate your symptoms.

Summary

Silent migraine is a type of migraine characterized by the absence of headache pain. Instead, you may experience symptoms such as:

• aura
• sensory disturbances
• cognitive impairments
• gastrointestinal issues

A doctor may diagnose a silent migraine through a detailed medical history, physical examination, and exclusion of other conditions. Treatment options include medication and lifestyle modifications such as regular exercise and stress management.

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