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rived from megrim, which in turn was derived from the Latin hemicrania and its corrupted forms hemigranea and migranea), the pain may be frontal, temporal, or quite often, generalized Milder forms of migraine, especially if partially controlled by medication, may not force the patient to withdraw from accustomed activities Any one of the three principal components neurologic abnormality, headache, and nausea and vomiting may be absent With advancing age, there is a tendency for the headache and nausea to become less severe, nally leaving only the neurologic abnormality ( aura without migraine ), which itself recurs with decreasing frequency This is also subject to variation Visual disturbances, by far the most common, differ in detail from patient to patient; numbness and tingling of the lips and the ngers of one hand are probably next in frequency, followed by transient aphasia or a thickness of speech and hemiparesis as mentioned earlier Rarely, there is sudden but transient blindness or a hemianopia at the onset, accompanied by only a mild headache All of these neurologic syndromes must be distinguished from transient ischemic attacks (TIA) and small strokes, which they resemble if the typical headache fails to follow the neurologic symptoms (see further on, under Stroke and TIA with Migraine ) Basilar Migraine A less common form of the migraine syndrome, with prominent brainstem symptoms, was described by Bickerstaff The patients, usually young women with a family history of migraine, rst develop visual phenomena like those of typical migraine except that they occupy the whole of both visual elds (temporary cortical blindness may occur) There may be associated vertigo, staggering, incoordination of the limbs, dysarthria, and tingling in both hands and feet and sometimes around both sides of the mouth These symptoms last 10 to 30 min and are followed by headache, which is usually occipital Some patients, at the stage when the headache is likely to begin, may faint, and others become confused or stuporous, a state that may persist for several hours or longer Exceptionally there is an alarming period of coma or quadriplegia The symptoms closely resemble those due to ischemia in the territory of the basilar-posterior cerebral arteries hence the name basilar artery or vertebrobasilar migraine Subsequent studies have indicated that basilar migraine, though more common in children and adolescents, affects men and women more or less equally over a wide age range, and that the condition is not always benign and transient (see further on, under Complicated Migraine ) Ophthalmoplegic and Retinal Migraine The former are recurrent unilateral headaches associated with weakness of extraocular muscles A transient third-nerve palsy with ptosis, with or without involvement of the pupil, is the usual picture; rarely, the sixth nerve is affected This disorder is more common in children The paresis often outlasts the headache by days or weeks; after many attacks, a slight mydriasis and, rarely, ophthalmoparesis may remain as permanent defects Retinal and anterior optic nerve ischemia has also been documented In some cases, the retinal arterioles are attenuated and sometimes there are retinal hemorrhages; in other cases, narrowing of retinal arteries or venules has been observed during an attack, as described in the cases reported by Berger and colleagues In still other cases, monocular blindness is associated with disc edema and peripapillary hemorrhages, and vision recovers only partially after several months (Hupp et al) Such events are referred to as retinal migraine, or, more accurately, ocular migraine, since either the retinal or the ciliary circulation may be involved It is well to remember that in adults the syndrome of headache, unilateral.

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BTX-A is contraindicated in patients with neuromuscular disorders, such as myasthenia gravis or amyotrophic lateral sclerosis, as these conditions may exaggerate the paralytic effect of the drug In addition, care should be exercised when administering BTX-A to patients who are taking medications that interfere with neuromuscular transmission, as these drugs may theoretically increase the paralytic effect of the toxin BTX-A should not be administered in any anatomic area with an active infection While BTX-A is classi ed as pregnancy category C and should be avoided in pregnant or lactating women, there have been no reports of complications in pregnant women who have incidental exposure to BTX-A prior to becoming aware of pregnancy3 Finally, patients with demonstrated allergy to any components of BTX-A should not be treated

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