CASE REPORT

Migraine with Aura or Sports-Related Concussion:

Case Report, Pathophysiology, and
Multidisciplinary Approach to Management
Michael J. Ellis, MD1,2,3,4,5,6; Dean Cordingley, MSc4,6; Richard Girardin, AT(C)4,6;
Lesley Ritchie, PhD4,6,7; and Janine Johnston, MD4,6,8,9
sports can present a diagnostic challenge for treating physicians because of
the overlap of clinical features between
SRC, several forms of headache, and
other neuro-ophthalmological conditions that accompany head trauma,
including traumatic optic neuropathy
(14,18,23Y25,30,43,52,62). Although
migraine headaches accompanied by
visual aura are typically benign and
do not require treatment, the evaluation of SRC patients presenting with
acute visual disturbance requires a
multidisciplinary approach including
experts with clinical training in TBI,
migraine, and neuro-ophthalmology
to arrive at the correct diagnosis and
initiate a management plan that limits
the risk of cumulative and potentially life-threatening injury (4,60) and promotes neurological recovery (15,61).
Here, we report a young athlete with a history of migraine with visual aura who presented with acute visual
disturbance and headache after a head injury sustained
during a hockey game. A brief review of the epidemiology,
classification, pathophysiology, clinical presentation, diagnostic considerations, and management of migraine with
visual aura is presented. Recommendations for SRC patients with this rare clinical presentation also are discussed.

Abstract
The evaluation and management of athletes presenting with clinical
features of migraine headache with aura in the setting of sports-related
head trauma is challenging. We present a case report of a 15-yr-old boy
with a history of migraine with visual aura that developed acute visual
disturbance and headache after a head injury during an ice hockey game.
The patient underwent comprehensive assessment at a multidisciplinary
concussion program, including neuro-ophthalmological examination, neurocognitive testing, and graded aerobic treadmill testing. Clinical history and
multidisciplinary assessment was consistent with the diagnosis of coexisting
sports-related concussion and migraine with brainstem aura. The authors
discuss the pearls and pitfalls of managing patients who develop migraine
headache with visual aura after sports-related head injury and the value of a
comprehensive multidisciplinary approach to this unique patient population.

Introduction
Sports-related concussion (SRC) is a form of traumatic
brain injury (TBI) that can present with a wide range of
clinical manifestations. Headaches and visual disturbances
are symptoms that commonly occur in the setting of acute
SRC but also are features of primary headache disorders
including migraine (57). Patients who present with migraine
with visual aura in the setting of acute head trauma during
1

Department of Surgery, University of Manitoba, Manitoba, Canada, 2Department

of Pediatrics and Child Health, University of Manitoba, Manitoba, Canada,
3
Section of Neurosurgery, University of Manitoba, Manitoba, Canada, 4Pan Am
Concussion Program, University of Manitoba, Manitoba, Canada, 5Childrens
Hospital Research Institute of Manitoba, Manitoba, Canada; 6Canada North
Concussion Network, Winnipeg, Manitoba, Canada; 7Department of Clinical
Health Psychology, University of Manitoba, Manitoba, Canada, 8Department of
Medicine and Ophthalmology, University of Manitoba, Manitoba, Canada,
9
Department of Neurology, University of Manitoba, Manitoba, Canada
Address for correspondence: Michael J. Ellis, MD, University of Manitoba,
Pan Am Clinic, 75 Poseidon Bay, Winnipeg, Manitoba, Canada R3M 3E4;
E-mail: mellis3@panamclinic.com.
1537-890X/1601/14Y18
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14

Volume 16 & Number 1 & January/February 2017

Case Report
The patient is a 15-yr-old boy with a medical history significant for two previous SRC and migraine headaches. The
migraine headaches had occurred three to four times and
were always characterized by the sudden onset of a fortified
scotoma that evolved over 15 to 30 min into either right or
left homonymous hemianopsia followed by severe and
throbbing headache, nausea, and occasional vomiting. In the
past, these migraine headaches were triggered by stress and
one episode of severe pain associated with a finger dislocation
but never by physical exercise. There was a family history of
migraine, and his mother suffered migraines that were often
Acute Migraine or Sports-Related Concussion

Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

preceded by visual auras and were associated with hemiparesis

and dysarthria. Neither the patient nor his mother had undergone genetic testing for familial hemiplegic migraine.
During an ice hockey game, the patient sustained a blindsided body check where the opponents shoulder impacted
the side of the patients head. The patient reported immediate
onset of mild headache, dizziness, blurred vision, and the
premonitory sensation that he was going to have a migraine.
After being immediately removed from the game, he noted
the presence of an incomplete homonymous hemianopsia
with the right eye affected more than the left. While on the
sidelines he developed severe headache, vomiting, worsening
of the homonymous hemianopsia followed by acute confusion and disorientation. The patient was transferred by ambulance to a pediatric emergency department where he
underwent urgent computerized tomography (CT) of the
brain and spine that demonstrated no abnormalities. Upon
later questioning, the patient did not recall events during the
time of the ambulance transfer and neuroimaging studies.
Approximately 6 h after the initial onset of symptoms, the
patient experienced complete resolution of headaches, visual
symptoms, and disorientation and was discharged from hospital after overnight observation.
The patient was referred to a pediatric concussion program
and underwent comprehensive multidisciplinary assessment
4 d after the date of injury. The patient underwent initial
consultation with a neurosurgeon who serves as the medical
director of the pediatric concussion program as well as further evaluation and testing by a neuro-ophthalmologist. At
the time of consultation, the patient endorsed symptoms of
fatigue and drowsiness but no other concussion-related
symptoms. The patient denied any blurred vision, diplopia,
or visual field deficit. Comprehensive neuro-ophthalmological
evaluation demonstrated intact visual acuity (20/30-3 OD,
20/25-2 OS) and color vision, normal pupillary function and
normal funduscopic examination. Ocular motor examination revealed orthophoric alignment in the primary position
at near and at distance and confirmed normal convergence,
smooth pursuit, saccades, and vestibulo-ocular reflex (VOR)
functioning. Automated visual field testing with Humphreys
perimetry central 30-2 threshold was normal. The remainder
of the physical examination including cranial nerve, motor,
sensory, deep tendon reflexes, balance, gait, cervical spine,
and cerebellar testing was normal.
Computerized neurocognitive testing using the Immediate Post-Concussion Assessment and Cognitive Testing
(ImPACT) tool was administered by a trained athletic therapist and interpreted by a licensed clinical neuropsychologist. All scores were found to fall within normal limits with
no borderline scores (percentiles scores ranged from 32% to
79%). There was no available baseline test to compare
postinjury results to in this patient. After neurocognitive
testing, the patient underwent physician-supervised Buffalo
Concussion Treadmill Testing undertaken by an exercise
physiologist and athletic therapist using previously described procedures (32,37). Treadmill testing elicited no
symptom-limiting threshold at a maximal blood pressure of
196/74 and maximal heart rate of 200 bpm suggestive of
physiological recovery.
Taking into account all clinical data collected during the
multidisciplinary assessment, the patient was diagnosed
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with SRC and migraine with typical and brain stem aura.
Given the patients clinical status and results of neurocognitive
and treadmill testing at the time of consultation, the patient
was managed with a graduated return-to-play program
resulting in successful return to full contact hockey. Before
full medical clearance, the patient was advised of the elevated
risk of future concussion given his lifetime history of concussion. The patient also was advised about the potential risk
that future hockey activities including head injury could
result in future migraines with a similar or more severe
clinical presentation.
Discussion
This case demonstrates the value of multidisciplinary assessment in patients with acute visual disturbances after
SRC and the challenges of managing patients who present
with clinical evidence of migraine headaches after sportsrelated head injury.
Migraine is the most common primary headache disorder
with an estimated prevalence of 15% to 20% in the general
population (31). This condition occurs in all age groups
with a peak incidence observed within the third and fourth
decades of life. Although a strong male predominance is
observed among pediatric migraine patients, the opposite is
seen in adulthood where the male-to-female ratio is 1:3
(59). Migraine has a strong genetic basis with a family history of migraine frequently reported among migraine patients and rare forms, such as familial hemiplegic migraine,
linked to specific gene mutations (28,58). Over the past 10
to 15 yr, the International Headache Society has provided
evolving criteria that guide the diagnosis and subclassification of migraine headaches. The most common form of
migraine that presents with visual disturbance is migraine
with aura, which must meet specific diagnostic criteria.
Other described forms of migraine that present with transient visual disturbance include retinal migraine and migraine with brainstem aura (21,22,55). Patients with visual
auras that persist for more than 1 h and are associated with
neuroimaging evidence of stroke are classified as migrainous infarction (26). In addition to visual disturbance, migraine with brainstem aura can present with decreased
levels of consciousness (21). Similarly, alterations of consciousness and confusion can occur during attacks of familial hemiplegic migraine. In children, acute confusional
migraine has been reported (52), and slowed cortical activation during acute migraine in children and adolescents
can contribute to cognitive dysfunction (63,64). However,
there is some debate as to whether confusional migraine in
children and adolescents is truly confusional or simply a
language disorder (29). Commonly reported triggers associated with migraine headaches include stress, lack of sleep,
bright lights, certain foods, and dehydration. In rare cases,
migraine-like headaches also can be triggered by head
trauma, with a significant proportion of reported cases described in children and adolescents who manifested with
headaches and a range of neurological impairments including
hemiparesis, blindness, confusion, and coma (24,25).
The pathophysiology of migraine headaches and acute
concussion remain controversial but may be closely related.
At present, migraine with aura is thought to arise from a
wave of spreading depolarization resulting in transient
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15

suppression of cortical activity (cortical spreading depression [CSD]) advancing 2 to 6 mmIminj1 (2,36). The visual
aura specifically occurs as a result of CSD that originates in
the striate cortex and is associated with alterations in regional cerebral blood flow (5,34,35). CSD in turn, causes
the headache phase of migraine by activating trigeminal
nociceptors that innervate large meningeal blood vessels,
followed by activation of central trigeminovascular neurons
(3,54). Similar to migraine, animal model evidence suggests
that concussion is mediated by alterations in excitatory
neurotransmitter release, neuronal depolarization, and cerebral blood flow (20). Indeed, neuroimaging studies have
demonstrated alterations in resting cerebral blood flow and
cerebrovascular responsiveness after concussion as well as
those with posttraumatic migraine headaches (49,50).
Comprehensive assessment of patients presenting with
visual disturbance and headache after sports-related head
trauma requires a multidisciplinary approach by experts with
clinical training and experience in TBI, migraine, and neuroophthalmology. Other conditions that can present with visual
disturbance in the setting of sports-related head injury, such
as traumatic cranial neuropathy, intraparenchymal hemorrhage, and vestibular dysfunction, must be ruled out before
this diagnosis can be made and managed appropriately.
Because the pathophysiology of CSD in migraine is cortical in origin, the hallmark of migraine with visual aura is
acute onset of binocular visual disturbance followed by
headache. Visual auras can manifest as positive or negative
phenomena that generally develop over minutes and persist
for up to 1 h in duration. Positive visual auras typically include a fortified scotoma that originates centrally expands
temporally in a hemianopic pattern and is associated with a
scintillating edge, flashing lights, colors, or waves. Negative
visual auras can range from mild blurred vision to a dense
homonymous hemianopsia. Visual auras also can be accompanied by other auras that present as sensorimotor or
speech deficits. By contrast, retinal migraine is rare. It is
typically monocular and manifests as negative, not positive
visual phenomena, including complete and incomplete visual loss or scotomata, altitudinal visual field defects, and
blurred vision (22,23,55). Many patients including children
have difficulty discriminating between visual auras that affect one or both eyes. Because the temporal visual field is
larger, patients frequently focus only on the visual phenomena in that field. Likewise, unlike adults, visual auras in
children are more likely bilateral, involving both visual
fields (29). Importantly, the visual phenomena that patients
with migraine experience must be distinguished from those
caused by traumatic optic neuropathy which also can arise
in the setting of pediatric acute SRC (18). Visual deficits
caused by traumatic optic neuropathy are monocular, usually fixed and can range from mild blurred vision to complete vision loss that often present at the time of injury but
in rare cases can present in a delayed fashion (39,44).
The headache that accompanies migraine with aura is typically described as unilateral, pulsating, moderate, or severe in
intensity and associated with photophobia, phonophobia,
nausea, and vomiting. In the majority of cases, the visual aura
precedes the onset of headache but in selected cases can
accompany the headache and be prolonged or can occur
without headache. Studies have demonstrated considerable
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Volume 16 & Number 1 & January/February 2017

overlap between the symptoms of migraine headaches

and SRC (30,43). Although acute SRC patients rarely meet
the International Classification of Headache Disorders
(ICHD)-3-beta criteria for migraine headaches, symptoms,
such as headache, nausea, photophobia, phonophobia, and
blurred vision, are commonly endorsed by these patients. In
contrast, however, acute visual field deficits or loss of vision
are not symptoms of SRC and should alert the physician to
other coexisting neurological conditions (14,18). After migraine
headache, many patients experience a period of fatigue or
drowsiness that can persist for days after the initial headache.
The physical examination of patients presenting with visual disturbances after head injury should always include
comprehensive assessment of vision, ocular motor, and
vestibular function as well as a complete neurological examination. Although in recent years, we have observed the
development of clinical and sideline tools that provide abbreviated assessment of some aspects of visual and ocular
motor function (19,48), these tools should never be used as
stand-alone tools by inexperienced clinicians to provide
comprehensive neuro-ophthalmological assessment of SRC
patients presenting with visual disturbance. Neuroophthalmological examination is frequently normal in patients with migraine with visual aura. In selected patients
with retinal migraine examined during an attack, loss of
visual acuity is accompanied by focal or segmental constriction of retinal arterioles and retina vein collapse, as well
as an ipsilateral relative afferent pupillary defect (22,23,55).
Physical examination findings in patients with traumatic
optic neuropathy can reveal abnormalities in visual acuity,
visual fields and color vision, ipsilateral relative afferent
pupillary defect, as well as disc edema on fundoscopy in the
affected eye (18,62).
Additional investigations can be useful in the assessment
of patients presenting with transient visual disturbance after
SRC and patients with suspected migraine headaches. Automated visual field testing is usually normal in patients
with migraine but in some cases can detect visual field defects if performed at the time of the visual field symptoms.
Neuroimaging in children and adolescents with migraines is
often normal (45). As illustrated here, CT studies are typically normal in pediatric patients with sports-related head
injury and are only indicated in the emergency department
setting (33,51). Magnetic resonance imaging (MRI) studies
also are normal in the majority of pediatric SRC patients
but should be considered in patients with abnormal CT
findings, focal neurological deficits, and persistent or worrisome symptoms (16). Although studies using advanced
MRI techniques, such as diffusion tensor imaging (DTI)
have demonstrated white matter changes in patients with
concussion (8,27,53), similar changes also have been observed in pediatric migraine patients without a history of
head injury (47). In general, children and adolescents with a
reliable history of migraine headaches who suffer a similar
event even in the setting of head trauma and have a normal
neuro-ophthalmological examination do not require neuroimaging. However, in patients with an unreliable clinical
history, monocular symptoms and those with abnormalities
on neuro-ophthalmological examination, MRI of the brain,
and optic pathways should be considered. Because the present patient described visual symptoms that were similar to
Acute Migraine or Sports-Related Concussion

Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

previous migraine attacks, had returned to his neurological

baseline, underwent a normal neuro-ophthalmological examination and initial CT imaging demonstrated no abnormalities, MRI was not considered in this child.
The management of pediatric migraine headaches continues to evolve. All pediatric migraine patients should be
advised to avoid identified migraine triggers as well as
maintain regular sleep, exercise, and hydration habits (41).
Children and adolescents with rare migraine headaches are
usually managed conservatively or with over-the-counter
medications, such as acetaminophen or ibuprofen (10,40).
Selected triptans also are approved for use in children as
abortive medications. In patients with more frequent or severe headaches, prophylactic pharmacological management
is considered using medications such as beta-blockers, tricyclic antidepressants, and anticonvulsants (9,42).
The evaluation and management of pediatric patients
presenting with migraine headaches in the setting of a
sports-related head injury is challenging. At present, there is
no gold standard diagnostic test for concussion and no
available sideline concussion instruments that can reliably
distinguish between SRC and migraine headaches. Some
authors suggest that neuropsychological testing can be used
as a supplemental tool to aid in the management of SRC
patients (46); however, there are limited evidence-based
guidelines to direct the use of these tools in children and
adolescents (12,13). In addition, studies have suggested that
graded aerobic treadmill testing also can serve as a useful
tool to assess physiological recovery after SRC (11,15,38).
Although the clinical history provided by the patient was
most consistent with a migraine headache that was similar
to previous attacks, the immediate onset of headache at the
time of injury, coupled with the limitations of currently
available diagnostic tools, makes it impossible to reliably
rule out a SRC in this patient. While the visual aura and
accompanying headache are most fitting with a diagnosis of
migraine with visual aura, the prolonged period of visual
disturbance, confusion, and disorientation make migraine
with typical and brainstem aura a more fitting diagnosis.
Given the risks of cumulative and catastrophic injury associated with premature return to play after SRC including
second impact syndrome (4,60), we recommend that all
patients, especially children and adolescents, who develop
clinical evidence of migraine headaches with visual aura in
the setting of sports-related head injury be managed as
concussion patients and undergo comprehensive assessment
by physicians with clinical training and experience in TBI,
migraine headaches, and neuro-ophthalmology. At our institution, we often consider the use of both neuropsychological and graded aerobic treadmill testing to confirm
neurocognitive and physiological recovery in pediatric SRC
patients especially in those with multiple concussions and
atypical clinical presentations (7,17).
Consequently, in the case presented here, only after documentation of a normal neuro-ophthalmological examination, normal computerized neurocognitive testing, and the
absence of a symptom-limiting threshold on graded aerobic
treadmill testing, was the patient medically cleared to initiate a physician-supervised graduated return-to-play program that ultimately resulted in successful return to full
contact hockey. Because of the patients history of two
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previous concussions and migraine headaches, the athlete

was advised about the cumulative risks of future concussions and the potential for future migraine headaches that
could reoccur during hockey activities.
Although not observed in the patient described here,
some SRC patients will present with subjective reports of
visual disturbance that do not resolve after a period of
physical and cognitive rest. In SRC patients who demonstrate objective evidence of vestibular dysfunction, there is
some preliminary evidence to suggest that targeted vestibular physiotherapy can enhance symptomatic recovery
(1,56). While vision therapy has received increased attention as a potential therapeutic option in TBI patients with
documented abnormalities of vergence (6), there are no
prospective controlled studies that have examined the clinical benefit of this intervention among SRC patients.
In conclusion, the evaluation and management of athletes presenting with visual disturbance and headache after head injury is challenging. Given the limitations of
currently available diagnostic tools in concussion, we
recommend that patients who present with clinical evidence of migraine headache with aura after sports-related
head injury be managed as concussion patients until
proven otherwise and undergo multidisciplinary assessment by physicians with clinical training in TBI, migraine,
and neuro-ophthalmology.

This report is supported by a grant from the Pan Am

Clinic Foundation, Winnipeg Jets True North Foundation,
and a generous donation by Leonard and Susan Asper.

The authors declare no conflict of interest and do not

have any financial disclosures relevant to this submission.

Dr. Ellis, Mr. Cordingley, Mr. Girardin, Dr. Ritchie, and

Dr. Johnston conceptualized and designed the study.
Drs. Ellis and Dr. Johnston drafted the initial manuscript, and
approved the final manuscript as submitted. Mr. Cordingley,
Mr. Girardin, and Dr. Ritchie contributed to data collection
and analysis. All authors critically reviewed and revised the
manuscript, and approved the final manuscript as submitted.

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