1 - Faculdade Israelita de Ciências e Saúde Albert Einstein (FICSAE) .
2 - Associação Brasileira de Cefaleia em Salvas e Enxaqueca (ABRACES).
3 - Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (IPQ-HCFMUSP).
4 - Instituto Israelita de Pesquisa Albert Einstein Hospital Israelita Albert Einstein (HIAE).
5 - Universidade Federal de Santa Catarina
6 - Headache Group, Department of Basic and Clinical Neurosciences, Kings College London, London, UK.
7 - Headache Center, Neurocenter of Southern Switzerland (NSI), Regional Hospital Lugano.
Introduction: Migraine is a common primary headache and a major cause of disability. In at least a third of migraine attacks, the headache is preceded and/or accompanied by aura and the visual manifestation is the most frequent phenotype. Migraine with aura, a subtype of migraine disorder, are underdiagnosed and undertreated. So, a detailed aura iconography is important for better recognition, prevention and treatment of migraine with aura. Objective: A visual aura art contest was performed by ABRACES (Brazilian Association of Cluster Headaches and Migraines), in order to provide new images for raising awareness among population and professionals and decreasing the gap between diagnosis and treatment. Methods: The contest involved free subscription of drawings, paintings and digital art that expressed realistic results of a visual aura of migraine and answering of a questionnaire. The awards were separated in two categories (painting/drawing and digital art/photography) and amounted up to R$ 5,000. Results: There were 139 participants, 24% men and 76% women. The most common visual aura’s characteristic was the presence of colorful points, and the less frequently was golden. The mean duration of visual aura was 110.6 minutes (450.5 of standard deviation), median of 20 minutes, minimum of 1 minute and maximum of 3600 minutes. 36.7% of the subscribers have only one kind of visual aura and 33.8% answered that have more than one kind. 46,5% said that their visual aura almost never occurs without pain after or while aura and 19% reported that their visual aura always occurs without a headache. Conclusion: Art contests are useful tools for disease awareness. Further actions in disseminating aura images may help migraine aura underdiagnosis and undertreatment.
Keywords: migraine; aura; advocacy.
Introdução: A enxaqueca é uma cefaleia primária comum e uma das principais causas de incapacidade. Em pelo menos um terço dos ataques de enxaqueca, a cefaleia é precedida e/ou acompanhada por aura e a manifestação visual é o fenótipo mais frequente. Enxaqueca com aura, um subtipo de enxaqueca, é subdiagnosticada e subtratada. Portanto, uma iconografia detalhada da aura é importante para um melhor reconhecimento, prevenção e tratamento da enxaqueca com aura. Objetivo: Um concurso de arte de aura visuais foi realizado pela ABRACES (Associação Brasileira de Dores de Cabeça e Enxaqueca), para que mais imagens possam ser usadas para aumentar a conscientização da população e dos profissionais, otimizando o diagnóstico e o tratamento. Métodos: O concurso envolveu inscrição gratuita de desenhos, pinturas, e arte digital e fotografia que expressavam resultados realistas de uma aura visual de enxaqueca e preenchimento de um questionário. Os prêmios foram separados em duas categorias (pintura/desenho e arte digital/fotografia), numa quantia até R$ 5.000. Resultados: Foram 139 participantes, 24% homens e 76% mulheres. A mais prevalente característica da aura visual foi a presença de pontos coloridos e menos frequentemente dourados. A duração média foi de 110,6 minutos (450,5 de desvio padrão), mediana de 20 minutos, mínimo de 1 minuto e máximo de 3600 minutos. 36,7% dos participantes possuem apenas um tipo de aura visual e 33,8% responderam que possuem mais de um tipo. 46,5% disseram que sua aura visual quase nunca ocorre sem dor após ou durante a aura e 19% relataram que sua aura visual sempre ocorre sem dor de cabeça. Conclusão: Concursos de arte são ferramentas úteis para a conscientização de doenças. Outras ações na disseminação de imagens da aura podem ajudar no subdiagnóstico e subtratamento da aura da enxaqueca.
Descritoress: enxaqueca; aura; advocacy.
Migraine is a common primary headache and a major cause of disability1. It is characterized by recurrent episodes of headache often associated with nausea, vomiting, photophobia and phonophobia. The annual prevalence in general population is an average of 12%, and it is more frequent in 25 to 55 years old individuals and women population2. Patients have episodic attacks separated by interictal phases. The attack is an interplay between genetic3 and environmental factors, possibly resulting in a dysfunctional state and structure alteration of the brain4,5.
In at least a third of migraine attacks, the headache is preceded and/or accompanied by reversible neurologic symptoms, named aura. This condition is classified as migraine with aura, a subtype of migraine disorder. In early descriptions, aura is linked to migraine since 1870, when Elliott showed the idea of migraine as a disorder characterized by aura, and associated with creativity, intellect, and visual disturbance.
According to Headache Classification Committee of the International Headache Society (IHS)6, aura is described as one or more of visual, sensitive, speech, motor, brainstem or retinal symptoms. Positive and/or negative visual manifestation is the most frequent phenotype, present in 98% of the patients7. Prevalent symptoms are flashes of bright light, foggy/blurred vision, zigzag or jagged lines, scotoma and phosphenes; and less frequent are more complex perception, such as misperception of distance, fractured vision, dysmorphopsias, tunnel vision, hemianopsia, curved or circular lines, among others8. Since visual auras varies in form, severity and duration both among patients and within each patient9, the anatomical location, extent and probably nature of the underlying occipital dysfunction must vary.
Migraine with aura are underdiagnosed and undertreated, partially because of misdiagnosis10. The consequences are chronic migraine, decreased quality of life and work productivity11–13. A detailed aura iconography is important for better recognition, prevention and treatment of migraine with aura.
An aura art contest was performed by ABRACES (Brazilian Association of Cluster Headaches and Migraines), so more images can be used for raising awareness of population and professionals, decreasing the gap between diagnosis and treatment.
The Art Contest Migraine Visual Aura by ABRACES involved free subscription of drawings, paintings, digital art and photography that expressed realistic results of a visual aura of migraine. The applications were open to September 22th until October 6th, 2019. The awards were separated in two categories (painting/drawing and digital art/photography) and were equivalent to up to R$ 5.000. The participants were people that have migraine with visual aura or people with artistic skills that asked somebody who has.
Visual aura was characterized as a disturbance of visual perception that occurs before the start of a migraine (or during), in a gradual way, lasting five minutes to one hour and completely reversible.
Some questions were ascertained, such as: “how did you hear about the contest?”, “are you submitting this work to someone else?”, “how long does your aura take on average (in minutes)?”, “do you have more than one type of aura?”, “does your visual aura occur without a headache?” and “what are the characteristics of your visual aura?”. Double data and data not properly filled were excluded to analyzing the results.
Categorical variables are presented as percentages and absolute number and continuous variables are presented as means with standard deviation, median, maximum and minimum data.
There were 139 participants in the contest. It was composed by 24% men and 76% women.
Most of participants heard about the contest by social medias: Instagram (38%) and Facebook (38%), 9% from google, 9% from ABRACES website, 5% from other vehicle of information and 1% from interview. The great majority submitted their own art expressing their visual aura.
Figure 1 detailed the prevalence of the characteristics of the visual aura. The most common was presence of points and colorful and the less common was golden. 20% of the participants answered that their visual aura has others features not mentioned.
The mean duration of visual aura was 110.6 minutes (450.5 of standard deviation), median of 20 minutes, minimum of 1 minute and maximum of 3600 minutes.
About the predominance of the pattern of visual aura, 36.7% of the subscribers have only one kind of visual aura and 33.8% answered that have more than one kind. Besides visual aura, 6% of the participants also present loss of strength in one half of the body, 9% have difficulty of speaking and 14.4% show tingling of in a half of face or body (Figures 2 and 3).
About the relation with headache, 8 participants did not fill the field. From 131 of the participants that answered, 46.5% said that their visual aura almost never occurs without pain after or while aura and 19% reported that their visual aura always occurs without a headache (Figures 4, 5 and 6).
The visual aura contest attracted a significant number of participants who contributed with representations of migraine auras. This helped us in generating new iconography of migraine aura and therefore will be of help in increasing awareness of this underdiagnosed condition. Art contests are a useful tool for awareness campaigns. The images uploaded were from a great variety of visual auras.
Aura features reported by the participants were like the ones described in previous papers8,14.
Further spread of the images is planned, a book with aura images is under development and hopefully will published soon. The same images could be uploaded and disseminated via social media and website / search engine such as Google. Indeed Health information is one of the most frequently searched topics on the Internet15.
Availability of aura images to the general public may increase aura diagnosis, improving the access to migraine or other headache sufferers because recognition of visual patterns by patients is likely to occur.
Art contests are useful tools for disease awareness. Further actions in disseminating aura images may help migraine aura underdiagnosis and undertreatment.
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