A migraine attack can occur without pain. This does not refer to a migraine aura not followed by a pain phase, but rather to the occurrence of migraine-related associated symptoms without pain. Migraine-associated symptoms refer to neurological and autonomic symptoms related to a migraine attack. Painless migraines may resemble abdominal migraine attacks, but in the latter, sensory hypersensitivity is absent. Painless migraine is poorly researched and is not found in the international headache classification (ICHD-3). My observation is that painless migraine seems to occur particularly during the subsiding phase of migraine, but occasionally even in 20-year-olds in addition to painful migraine attacks.
Typical symptoms
During a painless migraine, the most common symptoms are nausea, and sensitivity to light, sound, and smell. Olfactory sensitivity is not a criterion for migraine, although it is a very common symptom in a migraine attack. Usually, olfactory sensitivity occurs with nausea.
Vomiting is not an uncommon symptom in painless migraine. Many also experience intense fatigue, sweating, paleness, chills, and fluctuations in blood pressure or pulse due to autonomic nervous system dysfunction. Painless migraine often requires lying down. In addition, patients may experience gastrointestinal problems, such as diarrhea or constipation.
The attack lasts the typical 4–72 hours for migraine. Migraine-specific medications, or triptans, work to some extent, but prochlorperazine may be at least as effective. After the attack, the same symptoms as in typical migraine may occur: exhaustion, low mood, or euphoria.
Avitriptan and painless migraine
In the early 1990s, the Turku Headache Centre conducted studies on avitriptan. As an oral medication, it acted unusually quickly on migraine pain, even within 20–30 minutes, but did not affect associated symptoms.
Study participants described the drug as taking away the headache but leaving the migraine. Functionality did not return merely by eliminating the pain. This taught much about the impact of migraine's associated symptoms on functionality. However, avitriptan never made it to pharmacies.
Summary
Painless migraine is a difficult-to-recognize form of migraine that, despite the absence of pain, strongly affects functionality. Abdominal migraine is somewhat similar, but the lack of sensory hypersensitivity distinguishes these two forms of migraine.
Markku Nissilä, specialist in neurology
Frequently asked questions about painless migraine
Can migraine occur without pain?
Yes. A migraine attack can occur without headache, with symptoms including nausea, sensory hypersensitivity, and fatigue.
Is this different from a migraine aura without headache?
Yes. Migraine without pain is associated with concomitant symptoms, whereas aura without headache is a neurological phenomenon occurring before or without a pain phase.
Why is painless migraine difficult to diagnose?
Because pain is absent, symptoms can resemble other conditions, such as abdominal migraine or blood pressure fluctuations.
How is it treated?
Triptans can alleviate symptoms, but other medications such as prochlorperazine may also help. If necessary, preventive medication may be beneficial.
Is painless migraine dangerous?
Generally not, but it is advisable to confirm the cause of the symptoms with a neurological examination, especially if they differ from previous experiences.
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