Abstract
Dear Editor,
Petrusic et al. (1) listed 17 disorders of higher cortical functions during migraine auras. Another such disorder that I, and others, have experienced was described in a 1995 article published in Headache Quarterly (2), a journal that no longer exists and is not listed or retrievable in PubMed.
I was in my early 40s when, after a hectic day in the clinic, and concerned that I would be late for a dinner engagement, I realized that I couldn’t read while attempting to finish my charting, although my distant vision seemed normal. I had bilateral negative central scotomata, such as experienced after looking at a photo flash bulb. Indeed, I erroneously assumed that was the cause and expected the foveal bleach reaction to clear over the next 30–60 seconds. But, it persisted and after about five minutes, a fortification spectra appeared in my right lower quadrant and began moving centrally. I then realized what was happening and impatiently anticipated my first migraine headache. After the vision cleared, I had a very mild bilateral, nonpulsating headache that I might have ignored if not forewarned by the aura. If not preceded by the aura, it would have been classified as a tension-type headache, but the then extant International Classification of Headache Disorders (ICHD-1) stated that any headache following a typical migraine aura, was a “migraine.” As an aside, I was one of several who successfully argued to have “Typical aura with non-migraine headache” included in ICHD-II.
A year later, a similar event occurred while reading and, until the fortification appeared, I again deluded myself that it was photo flash-induced foveal bleach.
In 1975, Karl-Axel Ekbom (3) published a list of self-observations of his own, and other migrainous physicians, whose scintillations were preceded by very small negative scotomas that were evident only during reading. He described three difficulties migraineurs have in timing their auras: “‘muddled thinking’; failure to recognize it at once; and the impossibility of detecting it when not reading.”
Ekbom quoted E. Charles Kunkle who, in 1970, stated, “Patients who are having the visual phenomena of classic migraine are handicapped observers at the time; in part, this may arise from anxiety; in part, from ‘muddled thinking’, which some describe as part of the attack.”
Weinstein and Kahn (4) argued that “denial of illness” required a cognitive disturbance; otherwise, a cognizant person would not use such a primitive defense mechanism. My “muddled thinking” permitted me to conjure up a foveal bleach reaction caused by an imaginary, nonexisting flashbulb to explain away a migraine scotoma. When the third, and last, time the scotomas appeared, I immediately recognized it as an aura.
“Muddled thinking” may not be acceptable scientific terminology. “Confused thinking” might be a better term, but perhaps Petrusic and colleagues can suggest an alternative descripter.