What is a silent migraine?

Most people who experience migraine would consider their condition to be largely misunderstood by other people, especially those who have never had a migraine headache. But one subset of migraine is so misunderstood, even people who do have migraine may not know much about it: silent migraine, or migraine without pain.

If you’re wondering how you can have a headache without the…well, headache, we understand your confusion! Here’s what you need to know about the symptoms of silent migraine, who is most at risk for developing it, and how you can treat this headache-without-the-headache.

What is a silent migraine?

Silent migraine (or acephalgic migraine, in medical terms) is a migraine without the headache, but it’s not as strange as it sounds.

Migraine is more than just a bad headache—it’s a whole body experience. Looking at migraine through that lens makes it easier to understand the silent variety: You might have several other symptoms of migraine, such as aura, sensitivity to light, smells, or noise, and nausea or vomiting, but not the traditional throbbing or stabbing head pain typically associated with migraine. There are two classifications of migraine headaches. Classic migraine involves pain and aura, which has negative symptoms (numbness or loss of vision) or positive symptoms (visual spots, lines, or flickering lights, difficulty swallowing, or the sensation of pins or needles). Common migraine presents with pain, but no aura.

Traditional migraines aren’t dangerous in themselves, but they can lead to other problems such as dehydration and insomnia, plus they can affect your quality of life (by interfering with your ability to work or maintain relationships).

The same is true for silent migraine, says Medhat Mikhael, MD, a pain management specialist and medical director of the non-operative program at the Spine Health Center at MemorialCare Orange Coast Medical Center, though there is good reason not to ignore episodes of silent migraine.

“You want a neurological exam to rule out other problems that cause similar symptoms [like mini strokes or meningitis],” he explains. “With silent migraine, you’re also at higher risk for strokes in the future, so we keep an eye on [these patients] and follow them closely.”

Silent migraine symptoms

The symptoms of silent migraine are the same as traditional migraine, with the exception of head pain. In classic or common migraine (migraine with or without aura, respectively), people will have throbbing or stabbing pain, usually on one side of their head.

With silent migraine, you may experience:

• Moderate to severe aura symptoms, such as noticing strange smells, having numbness or tingling in the arms and neck, trouble hearing, weakness in arms, and loss of speech
• Sensitivity to bright lights and/or loud noises
• Sensitivity to particular smells
• Nausea and vomiting
• Vision changes, including seeing spots or wavy lines, or tunnel vision
• Common prodrome symptoms, like food cravings, irritability, fatigue, and neck stiffness

These are the symptoms of classic silent migraine. According to Clifford Segil, DO, a neurologist at Providence Saint John’s Health Center, ocular and hemiplegic migraine are also forms of silent migraine. Ocular migraine can temporarily affect your vision, causing blurriness and dizziness, while hemiplegic migraine comes with temporary stroke-like symptoms such as paralysis, weakness, or numbness on one side of the body.

The most effective diagnostic approach includes a thorough history and physical examination by your provider. For non-complicated common or classic migraines, the American Headache Society does not recommend routine neuroimaging. With some symptoms of silent migraine mimicking more serious conditions, it’s important to determine if you have silent migraine and not something else. For silent migraine, Dr. Mikhael says blood tests and brain imaging, either through a CT scan or MRI, can rule out any underlying issues. 

“If these symptoms are happening frequently, if there are visual changes, if you’re having intermittent weakness, or if it’s causing stress or lack of sleep,” you should talk to your doctor about how silent migraine is affecting your quality of life, advises Dr. Mikhael.

Silent migraine triggers

A family history of migraine or silent migraine is one of the biggest risk factors for experiencing silent migraine yourself. It’s also more common in women, says Dr. Mikhael, especially when they are in their childbearing years and coping with the fluctuating hormones associated with menstruation. It’s often less common during pregnancy or menopause because female hormones are largely stable during those reproductive phases.

Beyond a family history of migraine and hormonal triggers, there are many other common triggers for silent migraine. Most of them are the same as traditional migraine triggers, and include:

• Lack of sleep
• Stress or illness
• Caffeine or acute caffeine withdrawal
• Certain smells, sounds, or lighting
• Alcohol, especially wine
• Sudden changes in temperature or weather
• Dehydration or skipping meals
• Dietary ingredients, like preservatives (such as monosodium glutamate), nitrates, and artificial sweeteners
• Allergies
• Sexual intercourse

All migraine sufferers have different triggers, so it’s important to pay attention to what you do and what you consume in the hours before you have an episode to narrow down your personal triggers and try to avoid them. Some people find it helpful to keep a headache diary to review with their provider

Treatments for silent migraine

It can be a little trickier to treat silent migraine, if only because there’s no pain symptom that can be handled with an OTC pain reliever. Other than that, however, treatment of silent migraine isn’t much different than it is for traditional migraine (with a few exceptions).

First up is sensory deprivation: lying in a dark, quiet room can work wonders for soothing the sensory overload that may have triggered your migraine in the first place. If you can keep liquids down, be sure to hydrate since dehydration can worsen your symptoms.

You can also try alternative therapies, such as acupuncture, massage, and vitamin supplementation. Magnesium, for example, has been classified by the American Migraine Foundation as a supplement that is “probably effective” and generally considered safe for most people to use as a preventive treatment.

Finally, Dr. Segil says there are two pharmaceutical approaches to treating migraine: daily medications, which are taken to prevent episodes, and rescue medications, which are taken to relieve symptoms during an episode. Typically, doctors recommend using a daily medication if you have 14 or more migraine days per month. If you do not need daily preventive medication, then you can use rescue medication with symptoms. 

While both of these types of medications can be used to address silent migraine in most cases, Dr. Segil warns that hemiplegic migraine is often handled differently because of its stroke-like symptoms.

“You have to be more careful with rescue meds [like triptans] with hemiplegic migraine, because they can increase your stroke risk,” he says. “That trumps the frequency criteria and you may need a daily med [no matter how many days per month you have migraine].”

Pharmaceutical treatments for silent migraine

Prevention

Because it may be harder to identify and treat the symptoms of a pain-free migraine, prevention is really the key to having fewer episodes. It’s important to identify your triggers and avoid them as much as possible (or make a plan for treating any migraine that occurs when you can’t). Avoiding stress, getting enough sleep every night, and eating a healthy diet can also reduce the number of silent migraine episodes you have. When leaving your home, make sure you have a few doses of your migraine rescue medication with you. 

Don’t be afraid to talk to your doctor about a daily medication to prevent migraine if you think your migraine has become chronic, i.e. occurring more than 14 days per month. There are several “next generation” migraine drugs, like anti-calcitonin gene-related peptide (CGRP) injections and Nurtec ODT, that have been recently released to the market and are showing strong results in many patients.

“We used to just have repurposed seizure, blood pressure, and antidepressant medications to treat migraine,” says Dr. Sigal, “but we now have a blossoming of migraine treatments [that may be an option for you].”

Since silent migraine is basically aura without pain, it is important that women do not take estrogen containing products, especially combined hormonal contraception (pills, patch, or vaginal ring) as taking these medications can increase their risk of stroke or other cerebral event. 

One word of warning: Dr. Sigal notes that many of these new drugs come with a lack of data about their safety during pregnancy, so make sure you talk to your doctor if you are planning to become pregnant.