Learn when a suspected migraine attack with aura may indicate a stroke.

By Fernanda Bassette, from the Einstein Agency - One Saturday morning, right after drinking a cup of coffee, 58-year-old engineer Alexandre Godoi thought he would start the weekend with another severe migraine attack triggered by caffeine. He, who had no other pre-existing conditions and has suffered from chronic migraine with aura for years, noticed his vision beginning to blur (a classic sign of aura) and felt the pain in his head. 

As usual, he decided to take a painkiller and lie down in a dark room to wait for the attack to subside. The headache lessened, but his peripheral vision remained poor and persisted for more than 24 hours. Concerned about the permanent alteration of his visual field, the engineer went to the emergency room the next day and discovered that he had not had a severe migraine attack but a stroke (cerebrovascular accident), whose only symptom was the loss of visual field, which ended up being confused with an aura.

“The right side of my vision became blurry, like a fingerprint on a photograph. I could still see perfectly when I looked straight ahead, but my peripheral vision on the right side was impaired. Since I didn't have any other motor or physical symptoms, which are more common signs, I never imagined it was a stroke. I thought it was a migraine with a prolonged aura,” said Godoi.

Increased risk

Having migraine with aura (or migraine with aura, in technical terms) triples the risk of having a stroke. In fact, it has been recognized as a risk factor for such events in reviews of studies conducted at least ten years ago. 

According to neurologist Polyana Piza, from the Albert Einstein Israelite Hospital, a stroke can be ischemic (when there is a blockage of blood circulation in a specific region of the brain) or hemorrhagic (when there is a rupture of a cerebral blood vessel).

The first test to determine what is happening is a computed tomography (CT) scan, which is faster and differentiates between ischemic and hemorrhagic stroke – essential for determining the course of treatment. Then, depending on the need, a magnetic resonance imaging (MRI) scan is performed to confirm or rule out a stroke.

In the case of an ischemic stroke, if the patient seeks treatment within the first four and a half hours after the onset of symptoms, it is possible to reverse the condition through an intravenous procedure. Within 24 hours of the onset of symptoms, depending on the case, a mechanical thrombectomy (a catheterization procedure to remove the clot) may be possible. This is why it is so important for patients to know how to identify the signs that something is wrong, because the sooner they seek help, the lower the chance of lasting effects.

How to identify

Stroke is not always accompanied by physical or motor symptoms (such as paralysis on one side of the face, drooping mouth, difficulty speaking, loss of coordination). It all depends on the affected area – in Godoi's case, the affected region was the occipital region, responsible for the neurological interpretation of the visual field, hence the loss of peripheral vision. 

“The area most commonly affected is the one supplied by the middle cerebral artery, which is responsible for irrigating the motor system. That's why people are more accustomed to symptoms related to movement,” Piza explained.

One way to raise the alarm is to learn to identify the duration of the aura episode. In general, explains Polyana, the classic aura is characterized by temporary disturbances that include visual changes, blurred vision with the presence of flashes, lights, and spots that may move in the patient's visual field. It usually precedes the headache and lasts from five to 60 minutes – rarely longer. The aura disappears when the pain ceases and, along with it, the visual disturbances disappear.

“If a patient arrives at a doctor's office or emergency room reporting an acute visual disturbance, it is necessary to investigate and they must necessarily undergo an imaging exam for a correct diagnosis,” emphasized the neurologist. “Any acute symptom in neurology is primarily caused by a vascular problem, even if it is not persistent,” she said. In Godoi's case, what he suffered was not a migraine with aura, but a stroke – the duration of the supposed aura was the warning sign.

Stroke is the leading cause of morbidity and the second leading cause of death worldwide. According to the specialist from Einstein Hospital, one in four patients who suffer from migraines experience an episode with aura. Piza emphasizes that the best way to prevent stroke is to have regular check-ups with a neurologist for prophylactic treatment, which avoids the occurrence of migraine attacks. "There are different classes of medications indicated for different patient profiles," she said.