Does the migraine aura reflect cortical organization?

Migraine Visual Aura and Cortical Spreading Depression-Linking Mathematical Models to Empirical Evidence

This review describes the subjective experience of visual aura in migraine, outlines theoretical models of this phenomenon, and explores how these may be linked to neurochemical, electrophysiological, and psychophysical differences in sensory processing that have been reported in migraine with aura. Reaction-diffusion models have been used to model the hallucinations thought to arise from cortical spreading depolarisation and depression in migraine aura. One aim of this review is to make the underlying principles of these models accessible to a general readership. Cortical spreading depolarisation and depression in these models depends on the balance of the diffusion rate between excitation and inhibition and the occurrence of a large spike in activity to initiate spontaneous pattern formation. We review experimental evidence, including recordings of brain activity made during the aura and attack phase, self-reported triggers of migraine, and psychophysical studies of visual processing in migraine with aura, and how these might relate to mechanisms of excitability that make some people susceptible to aura. Increased cortical excitability, increased neural noise, and fluctuations in oscillatory activity across the migraine cycle are all factors that are likely to contribute to the occurrence of migraine aura. There remain many outstanding questions relating to the current limitations of both models and experimental evidence. Nevertheless, reaction-diffusion models, by providing an integrative theoretical framework, support the generation of testable experimental hypotheses to guide future research.

Vision and migraine

BACKGROUND

Migraine, a common brain disorder, disrupts vision more than any other motor or sensory function. The possible visual aura symptoms vary from occasional small flashes of light to complex visual hallucinations, the stereotyped teichopsia being the most typical pattern. It is unclear as to why aura occurs serendipitously, sometimes preceding, but also occurring after the headache, and why aura can present with multiple phenotypes.

METHODS

To better understand the nature of visual disturbances in migraine, 4 aspects must be considered: What are the visual perceptions in migraine; why vision is affected in migraine; the role of cortical spreading depression (CSD); how does vision could affect migraine. Evidence supporting each of these topics is reviewed.

RESULTS

CSD travels at a similar pace as the march of symptoms in the visual field. Functional neuroimaging studies show spreading changes compatible with CSD regardless of aura. Computerized models reproducing the CSD march on the visual cortex predict a sensory experience compatible with naturally occurring visual auras. Rather than spreading in all directions, these models suggest that CSD moves preferentially in one direction. Migraine-preventive drugs increase the CSD threshold and reduce CSD velocity. Blind migraineurs may present atypical visual aura, with more colors, shorter duration, different shapes, and atypical symptoms, such as auditory experiences.

CONCLUSIONS

CSD is the underlying phenomenon in migraine with and without aura. In migraine without aura, CSD probably does not run over silent areas of the cortex, but rather does not reach symptomatology threshold. Normal vision is important in migraine, as lack of sight may change the visual experience during migraine aura, probably due to cortical reorganization and changes in local susceptibility to CSD.

Aura-like features and photophobia in sightless migraine patients

Migraine is a central nervous system disorder frequently expressed with paroxysmal visual dysfunctions. Objective To test the hypothesis that normal visual input is vital for the migrainous aura and photophobia. Method We studied the migraine-related visual disturbances in 8 sightless migraineurs identified among 200 visually impaired subjects. Results The main findings were the visual aura and photophobia disappearance along with blindness development, the oddness of aura – too short, colourful (e.g. blue or fire-like), auditory in nature or different in shape (round forms) – and the lack of photophobia. Conclusion We propose that the aura duration should be accepted as shorter in visually impaired subjects. The changes in aura phenotype observed in our patients may be the result of both cerebral plasticity induced by the visual impairment and/or the lack of visual input per se. Integrity of visual pathways plays a key role in migraine visual aura and photophobia.

Migraine generator network and spreading depression dynamics as neuromodulation targets in episodic migraine

Migraine is a common disabling headache disorder characterized by recurrent episodes sometimes preceded or accompanied by focal neurological symptoms called aura. The relation between two subtypes, migraine without aura (MWoA) and migraine with aura (MWA), is explored with the aim to identify targets for neuromodulation techniques. To this end, a dynamically regulated control system is schematically reduced to a network of the trigeminal nerve, which innervates the cranial circulation, an associated descending modulatory network of brainstem nuclei, and parasympathetic vasomotor efferents. This extends the idea of a migraine generator region in the brainstem to a larger network and is still simple and explicit enough to open up possibilities for mathematical modeling in the future. In this study, it is suggested that the migraine generator network (MGN) is driven and may therefore respond differently to different spatio-temporal noxious input in the migraine subtypes MWA and MWoA. The noxious input is caused by a cortical perturbation of homeostasis, known as spreading depression (SD). The MGN might even trigger SD in the first place by a failure in vasomotor control. As a consequence, migraine is considered as an inherently dynamical disease to which a linear course from upstream to downstream events would not do justice. Minimally invasive and noninvasive neuromodulation techniques are briefly reviewed and their rational is discussed in the context of the proposed mechanism.

Transient localized wave patterns and their application to migraine

Transient dynamics is pervasive in the human brain and poses challenging problems both in mathematical tractability and clinical observability. We investigate statistical properties of transient cortical wave patterns with characteristic forms (shape, size, duration) in a canonical reaction-diffusion model with mean field inhibition. The patterns are formed by ghost behavior near a saddle-node bifurcation in which a stable traveling wave (node) collides with its critical nucleation mass (saddle). Similar patterns have been observed with fMRI in migraine. Our results support the controversial idea that waves of cortical spreading depression (SD) have a causal relationship with the headache phase in migraine and, therefore, occur not only in migraine with aura (MA), but also in migraine without aura (MO), i.e., in the two major migraine subtypes. We suggest a congruence between the prevalence of MO and MA with the statistical properties of the traveling waves' forms according to which two predictions follow: (i) the activation of nociceptive mechanisms relevant for headache is dependent upon a sufficiently large instantaneous affected cortical area; and (ii) the incidence of MA is reflected in the distance to the saddle-node bifurcation. We also observed that the maximal instantaneous affected cortical area is anticorrelated to both SD duration and total affected cortical area, which can explain why the headache is less severe in MA than in MO. Furthermore, the contested notion of MO attacks with silent aura is resolved. We briefly discuss model-based control and means by which neuromodulation techniques may affect pathways of pain formation.

Structural and functional neuroimaging in migraine: insights from 3 decades of research

Modern imaging methods provide unprecedented insights into brain structure, perfusion, metabolism, and neurochemistry, both during and between migraine attacks. Neuroimaging investigations conducted in recent decades bring us closer to uncovering migraine as a multifaceted, primarily central nervous system disorder. Three main categories of structural and functional brain changes are described in this review, corresponding to the migrainous aura, ictal headache, and interictal states. These changes greatly advance our understanding of multiple pathophysiologic underpinnings of migraine, from central "migraine generating" loci, to cortical spreading depression, intimate mechanisms underlying activation of neuronal pain pathways in vulnerable patients, central sensitization, and chronification. Structural imaging begins to explain the complex connections between migraine and cerebral vascular events, white matter lesions, grey matter density alterations, iron deposition, and microstructural brain damage. Selected structural and functional alterations of brain structures, as identified with imaging methods, may represent the foundation of new diagnostic strategies and serve as markers of therapeutic efficacy.

[Headaches from an ophthalmological perspective]

Headaches are a common and widespread complaint. Differential diagnostics are crucial for successful therapy and often require an interdisciplinary approach. General practitioners tend to refer patients with extraordinary types of headaches to physicians specialized in neurology, ophthalmology and otolaryngology. This article offers an overview about the range of headache disorders particularly associated with the ophthalmologic anatomy and function.

Flicker-light induced visual phenomena: frequency dependence and specificity of whole percepts and percept features

Flickering light induces visual hallucinations in human observers. Despite a long history of the phenomenon, little is known about the dependence of flicker-induced subjective impressions on the flicker frequency. We investigate this question using Ganzfeld stimulation and an experimental paradigm combining a continuous frequency scan (1-50 Hz) with a focus on re-occurring, whole percepts. On the single-subject level, we find a high degree of frequency stability of percepts. To generalize across subjects, we apply two rating systems, (1) a set of complex percept classes derived from subjects' reports and (2) an enumeration of elementary percept features, and determine distributions of occurrences over flicker frequency. We observe a stronger frequency specificity for complex percept classes than elementary percept features. Comparing the similarity relations among percept categories to those among frequency profiles, we observe that though percepts are preferentially induced by particular frequencies, the frequency does not unambiguously determine the experienced percept.

Migraine aura: retracting particle-like waves in weakly susceptible cortex

Cortical spreading depression (SD) has been suggested to underlie migraine aura. Despite a precise match in speed, the spatio-temporal patterns of SD observed in animal cortex and aura symptoms mapped to the cortical surface ordinarily differ in aspects of size and shape. We show that this mismatch is reconciled by utilizing that both pattern types bifurcate from an instability point of generic reaction-diffusion models. To classify these spatio-temporal pattern we suggest a susceptibility scale having the value sigma = 1 at the instability point. We predict that human cortex is only weakly susceptible to SD (sigma<1), and support this prediction by directly matching visual aura symptoms with anatomical landmarks using fMRI retinotopic mapping. Moreover, we use retinal SD to give a proof of concept of the existence of this instability point and describe how cortical susceptibility to SD must be adjusted for migraine drug testing. Close to the instability point at sigma = 1 the dynamical repertoire of cortical tissue is increased. As a consequence, the picture of an engulfing SD that became paradigmatic for migraine with aura needs to be modified in most cases towards a more spatially confined pattern that remains within the originating major gyrus or sulcus. Furthermore, we discuss the resulting implications on migraine pharmacology that is hitherto tested in the regime (sigma>1), and potentially silent aura occurring below a second bifurcation point at sigma = 0 on the susceptible scale.

Microstimulation of visual cortex to restore vision

This review argues that one reason why a functional visuo-cortical prosthetic device has not been developed to restore even minimal vision to blind individuals is because there is no animal model to guide the design and development of such a device. Over the past 8 years we have been conducting electrical microstimulation experiments on alert behaving monkeys with the aim of better understanding how electrical stimulation of the striate cortex (area V1) affects oculo- and skeleto-motor behaviors. Based on this work and upon review of the literature, we arrive at several conclusions: (1) As with the development of the cochlear implant, the development of a visuo-cortical prosthesis can be accelerated by using animals to test the perceptual effects of microstimulating V1 in intact and blind monkeys. (2) Although a saccade-based paradigm is very convenient for studying the effectiveness of delivering stimulation to V1 to elicit saccadic eye movements, it is less ideal for probing the volitional state of monkeys, as they perceive electrically induced phosphenes. (3) Electrical stimulation of V1 can delay visually guided saccades generated to a punctate target positioned in the receptive field of the stimulated neurons. We call the region of visual space affected by the stimulation a delay field. The study of delay fields has proven to be an efficient way to study the size and shape of phosphenes generated by stimulation of macaque V1. (4) An alternative approach to ascertain what monkeys see during electrical stimulation of V1 is to have them signal the detection of current with a lever press. Monkeys can readily detect currents of 1-2 microA delivered to V1. In order to evoke featured phosphenes currents of under 5 microA will be necessary. (5) Partially lesioning the retinae of monkeys is superior to completely lesioning the retinae when determining how blindness affects phosphene induction. We finish by proposing a future experimental paradigm designed to determine what monkeys see when stimulation is delivered to V1, by assessing how electrical fields generated through multiple electrodes interact for the production of phosphenes, and by depicting a V1 circuit that could mediate electrically induced phosphenes.

Migraine aura and related phenomena: beyond scotomata and scintillations

Migraine affects the cortical physiology and may induce dysfunction both ictally and interictally. Although visual symptoms predominate during aura, other contiguous cortical areas related to less impressive symptoms are also impaired in migraine. Answers from 72.2% migraine with aura and 48.6% of migraine without aura patients on human faces and objects recognition, colour perception, proper names recalling and memory in general showed dysfunctions suggestive of prosopagnosia, dyschromatopsia, ideational apraxia, alien hand syndrome, proper name anomia or aphasia, varying in duration and severity. Symptoms frequently occurred in a successively building-up pattern fitting with the geographical distribution of the various cortical functions. When specifically inquired, migraineurs reveal less evident symptoms that are not usually considered during routine examination. Spreading depression most likely underlies the aura symptoms progression. Interictal involvement indicates that MWA and MWoA are not completely silent outside attacks, and that both subforms of migraine may share common mechanisms.

What Delay Fields Tell Us About Striate Cortex

It is well known that electrical activation of striate cortex (area V1) can disrupt visual behavior. Based on this knowledge, we discovered that electrical microstimulation of V1 in macaque monkeys delays saccadic eye movements when made to visual targets located in the receptive field of the stimulated neurons. This review discusses the following issues. First, the parameters that affect the delay of saccades by microstimulation of V1 are reviewed. Second, the excitability properties of the V1 elements mediating the delay are discussed. Third, the properties that determine the size and shape of the region of visual space affected by stimulation of V1 are described. This region is called a delay field. Fourth, whether the delay effect is mainly due to a disruption of the visual signal transmitted through V1 or whether it is a disturbance of the motor signal transmitted between V1 and the brain stem saccade generator is investigated. Fifth, the properties of delay fields are used to estimate the number of elements activated directly by electrical microstimulation of macaque V1. Sixth, these properties are used to make inferences about the characteristics of visual percepts induced by such stimulation. Seventh, the disruptive effects of V1 stimulation in monkeys and humans are compared. Eighth, a cortical mechanism to account for the disruptive effects of V1 stimulation is proposed. Finally, these effects are related to normal vision.

Saccade-Related Spread of Activity Across Superior Colliculus May Arise From Asymmetry of Internal Connections

The superior colliculus (SC) receives a retinotopic projection of the contralateral visual field in which the representation of the central field is expanded with respect to the peripheral field. The visual projection forms a nonlinear, approximately logarithmic, map on the SC. Models of the SC commonly assume that the function defining the strength of neuronal connections within this map (the kernel) depends only on the distance between two neurons, and is thus isotropic and homogeneous. However, if the connection strength is based on the distance between two stimuli in sensory space, the kernel will be asymmetric because of the nonlinear projection onto the brain map. We show, using a model of the SC, that one consequence of these asymmetric intrinsic connections is that activity initiated at one point spreads across the map. We compare this simulated spread with the spread observed experimentally around the time of saccadic eye movements with respect to direction of spread, differing effects of local and global inhibition, and the consequences of localized inactivation on the SC map. Early studies suggested that the SC spread was caused by feedback of eye displacement during a saccade, but subsequent studies were inconsistent with this feedback hypothesis. In our new model, the spread is autonomous, resulting from intrinsic connections within the SC, and thus does not depend on eye movement feedback. Other sensory maps in the brain (e.g., visual cortex) are also nonlinear and our analysis suggests that the consequences of asymmetric connections in those areas should be considered.

A computational perspective on migraine aura

The classical visual aura of migraine is characterized by a unilateral hallucination, composed of a zigzag fortification pattern followed by a trailing scotoma. This pattern usually starts in central vision, expands and spreads to the periphery, and then disappears. We review a number of historical attempts to explain the migraine aura in terms of brain events, then summarize recent theories of the pathophysiology of the aura. We describe an approach to the computational modeling of migraine aura, based on the principles of (a) cortical organization, and (b) active wave propagation in an excitable medium. We demonstrate correspondences between properties of the model system and aspects of the pathophysiology of the aura. The simulations produced by the model are in agreement with descriptions and drawings of visual aura from migraine patients. We outline several testable predictions stemming from the implementation of the model, and explain how model-based empirical research has the capacity to (a) improve recording of the phenomena of the visual aura, (b) improve understanding of the spatio-temporal dynamics of other types of aura, in particular somatosensory and dysphasic aurae, and (c) clarify the theoretical requirements for the initiation of aura in the brain.

Komplexe Halluzinationen im Migräneanfall bei 10-jährigem Patienten - eine Fallbeschreibung und Übersichtsarbeit

Zusammenfassung: Fragestellung: Die Migräne ist bei Kindern mit einer Prävalenz von drei bis zehn Prozent eine häufige Erkrankung. Visuelle Auren sind als Charakteristikum der klassischen Migräne in der Literatur ausgiebig beschrieben. Vornehmlich handelt es sich um primäre Halluzinationen, Beschreibungen komplexer Halluzinationen hingegen sind kaum zu finden. Die vorliegende kasuistische Darstellung beinhaltet nach unserem Wissen das jüngste beschriebene Alter von komplexen Halluzinationen während einer Migräneattacke. Mögliche pathophysiologische Mechanismen und differentialdiagnostische Überlegungen werden auf Grundlage der bestehenden Literatur diskutiert. Methode: Dargelegt wird die Kasuistik eines 10-jährigen Patienten, welcher von einer komplexen visuellen Halluzination bei einer Migräneattacke berichtet. Es werden Symptomatik, Vorgeschichte sowie diagnostische Schritte dargestellt. Differentialdiagnostisch zu einer migränösen Aura werden das «Alice-in-Wonderland-Syndrom», «Liliputanische Halluzinationen», die Basilarmigräne sowie eine epileptische Genese diskutiert. Schlussfolgerung: Für komplexe Halluzinationen bei Migräne ist vermutlich ein analoger Pathomechanismus zu den primären Halluzinationen der migränösen Aura anzunehmen, so dass durch die vorliegende Arbeit die große Variabilität der migränösen Aura erneut unterstrichen wird.

The neural basis of Charles Bonnet hallucinations: a hypothesis

OBJECTIVES

To describe the hallucinations occurring as a result of a macular hole in each eye and to investigate the neural basis.

METHODS

Psychophysical observations including sketches of the hallucinations calibrated for size.

RESULTS

All the hallucinations were of the geometric (patterned) type and lasted for only a few days.

CONCLUSIONS

The observations can be explained on the basis of a "deafferentation" model, which is described in some detail. It is proposed that the hallucinations result from activation of the "blobs" of area V1 and the "stripes" of area V2 in the visual cortex. A theory is proposed to account for the disappearance of the hallucinations by a "filling in" mechanism.