96 Headache Medicine, v.2, n.3, p.96-98, Jul./Aug./Sep. 2011

Migraine with aura attacks overriding dreams

Ataques de migrânea com aura sobrepondo sonhos

ABSTRACTABSTRACT

ABSTRACT

While the anatomical pathways involved in migraine with aura

are near to be completely known, those involved in dreaming

remain less studied. We aimed to describe two cases of migraine

with visual aura, whose migraine auras would override their

dreams, and to discuss the pathways involved in visual aura

and in dreams. The following hypothesis can derive from the

above mentioned cases: a) visual aura projects over hippo-

campal and parahippocampal image templates where they

fuse in an unique image; b) memory banks use the extrastriatal

occipital cortex to form they image templates, fusion with visual

aura occurring during this process; c) both process occur

independently, but fuse within visual association areas. The

description of case reports like the two above is important to

understand the aura phenomenon and the dreaming process

and to reinforce the cortical role for these manifestations.

Keywords:Keywords:

Keywords: Visual aura; Migraine; Dream.

RESUMORESUMO

RESUMO

Enquanto as vias anatômicas da migrânea com aura estão

perto de ser completamente conhecidas, aquelas relacionadas

ao sonho permanecem pouco estudadas. Objetivamos

descrever dois casos de migrânea com aura visual, cujas

auras enxaquecosas sobrepõem seus sonhos e discutir as vias

envolvidas na aura visual e nos sonhos. As seguintes hipóteses

podem derivar dos casos acima mencionados: a) aura visual

é projetada sobre modelos de imagens hipocampal e para-

hipocampal, onde elas se fundem em uma única imagem; b)

bancos de memória usam o córtex occipital extraestriado para

formar modelos de imagens, a fusão com a aura visual ocorre

durante este processo; c) ambos os processos ocorrem

independentemente, porém fundem-se em áreas de associação

CASE REPORTCASE REPORT

CASE REPORT

Kowacs PA

1,2

, Carneiro RD

, Piovesan EJ

, Lange MC

, Santos PSF

Neurology Service, Department of Internal Medicine, Clinical Hospital,

Universidade Federal do Paraná, Curitiba, PR, Brazil

Neurology Service, Neurology Institute of Curitiba, PR, Brazil

Medical student, Universidade Federal do Paraná, Curitiba, PR, Brazil

Medical student, Universidade Federal de Sergipe, Aracaju, SE, Brazil

Kowacs PA, Carneiro RD, Piovesan EJ, Lange MC, Santos PSF. Migraine with aura attacks

overriding dreams. Headache Medicine. 2011;2(3):96-98

visual. A descrição de relatos de caso como os dois acima é

importante para entender o fenômeno aura e o processo do

sonho e reforçar o papel cortical para essas manifestações.

alavrasalavras

alavras

chave:chave:

chave: Aura visual; Migrânea; Sonhos

INTRODUCTION

Anatomy of migraine has been the subject of several

studies in the last decades, although migraine is currently

considered to be a non-specific response to central nervous

system hyperexcitability/dysinhibition states. For migraine

with aura, cortical spreading depression (CSD) is the most

likely candidate to be the primum phenomenon.

Migraine aura is a cortical phenomenon, that usually

involves the visual cortex.

2,3

It usually occurs concomitantly

to the input of visual stimuli, it is conceivable that migraine

aura and visual input are usually fused.

Nevertheless, migraine aura is known to occur

independently from visual stimuli, since it is reported to

occur while both eyes are shut or in blind migraineurs.

The occurrence of migraine aura overriding dreams,

although not original,

5-7

gives an excellent opportunity to

speculate about the pathways involved in migraine aura

and in dreams. The cases of two patients with migraine

with visual aura are reported, whose visual aura symptoms,

Headache Medicine, v.2, n.3, p.96-98, Jul./Aug./Sep. 2011 97

if initiated during sleep, would override their dreams,

and the pathways possibly involved in visual aura and in

dreams are discussed. This study was approved by the

Committee for Ethics in Research involving Human Beings

of the Neurology Institute of Curitiba (CEP 077/11-0).

CASE REPORTS

Case 1Case 1

Case 1

A 30 year-old caucasian female presented with the

complaint of migraine with aura attacks that had started

at the age of eight. Her aura always started with blurring

of her right hemifield followed by a right hemianopsia

lasting two minutes. After the hemianopsia a bright

fortification spectra would start in her right inferior quadrant,

marching counterclockwise. After a complete turn, its

frequency reduced progressively, and it would became

dysmorphic and occurring at random. The complete aura

used to last 45 minutes. A bilateral throbbing headache,

fulfilling all the criteria for migraine, used to follow the

aura. Sometimes, while asleep and dreaming, her usual

aura would override her dreams imagery. Although she

was not able to tell how long her aura lasted before waking

up, she would wake up having the same type of migraine

attack she used to have while awake. The rest of her

medical and family history was unremarkable. Her physical

and neurological examinations were normal. She was

submitted to a MRI of the head and to an EEG investigation

which did not disclosed abnormalities.

Case 2Case 2

Case 2

A 33 year-old caucasian female was seen because

of a migraine with visual aura which started at the age of

30 years. Her visual aura consisted of cintillating scotomata

at her left visual hemifield, lasting 15 minutes. Her visual

aura was followed by a migrainous throbbing headache.

Since the beginning, episodes would occur at a frequency

of 3-4 a month. Episodes could be triggered by physical

efforts and by dreams while asleep linked to specific dream

content. Her mother had migraine with aura of the chiro-

oral paresthesias. Her MRI of the head was unremarkable.

DISCUSSION

The anatomic pathways of migraine visualThe anatomic pathways of migraine visual

The anatomic pathways of migraine visual

auraaura

aura

As mentioned before, aura seems to reflect the

process of CSD, despite the fact that subcortical structures

such as the thalamus seem to be involved. The visual cortex

is known to be the starting zone of most of the migraine

auras. Aura-related CSD is known to involve not only the

primary visual cortex (V1), at the peristriated areas, but

also their closely associated visual unimodal association

areas (V2, V3, V4) and other extrastriated areas (V3/VP,

V3A, V4v).

1,2

The anatomic pathways of visual dreams.The anatomic pathways of visual dreams.

The anatomic pathways of visual dreams.

The anatomic pathways of dreams are not well

understood, but there is an agreement that dreams

originate in the memory banks at the hippocampal and

parahippocampal areas. Some studies using functional

neuroimaging showed that during rapid-eye movement

sleep, significant activations were found in the pontine

tegmentum, thalamic nuclei, limbic areas (amygdaloid

complexes, hippocampal formation, anterior cingulate

cortex) and in the posterior cortices (temporo-occipital

areas in extrastriate areas).

In 1980, Meyer and

colleagues, by using Xenon 133 inhalation, have shown

an increase in gray matter blood flow in the parieto-

occipital zones during dreaming and during hipnagogic

allucinations.

The cases described above illustrate puzzling situations

involving the processing of stored visual imagery and visual

input.

Hypothesis derived from the above mentionedHypothesis derived from the above mentioned

Hypothesis derived from the above mentioned

casescases

cases

1) Visual aura projects over hippocampal and

parahippocampal image templates where they may

fuse with dreaming imagery in an unique image; 2)

memory banks use the extrastriatal occipital cortex to

form the image templates and the fusion with visual

aura imagery may occur during this process; c) both

process may occur independently but fuse within visual

association areas.

The phenomenological analysis of the cases above

give us clues for understanding the migraine visual aura

phenomenon and to reinforce the cortical role for this

important manifestation in these patients.

ACKNOWLEDEGEMENTS

The authors express their appreciation to Ms. Marisa

Avelar de Morais for the review of style.

MIGRAINE WITH AURA ATTACKS OVERRIDING DREAMS

98 Headache Medicine, v.2, n.3, p.96-98, Jul./Aug./Sep. 2011

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Correspondence

edro André Kedro André K

edro André K

owacs, M.Dowacs, M.D

owacs, M.D

Instituto de Neurologia de Curitiba

Rua Jeremias Maciel Perretto, 300

81210-310 – Curitiba, PR,Brasil

phone/fax: + 41 3285.6613

pkowacs@gmail.com

KOWACS PA, CARNEIRO RD, PIOVESAN EJ, LANGE MC, SANTOS PSF