Silent migraine: symptoms you might overlook

A silent migraine is a migraine attack without the headache. Most often it means a migraine aura without headache, such as zigzag lines or flickering lights, but the term is also used for attacks where symptoms like brain fog, neck stiffness and tiredness take centre stage while the head does not hurt. Because there is no clear pain, a silent migraine is easy to miss.

You feel foggy. Your concentration drops away. Your neck slowly stiffens. But you have no headache, so it cannot be migraine, can it? Quite possibly it is. Migraine can show itself in many ways, and the most disabling symptoms do not always involve the head.

What is a silent migraine?

"Silent migraine" is not an official medical term. Doctors usually call it migraine aura without headache (typical aura without headache, sometimes called acephalgic migraine). People also use it more loosely for attacks without aura in which the other migraine symptoms are present but the headache is mild or missing. Either way, the word "silent" fits: the attack happens without the people around you noticing what is going on.

This happens because migraine starts in the brain. When the nervous system becomes oversensitive, as it does in migraine, it sets off a whole cascade of effects. Headache is only one of them. In a silent migraine the pain is skipped, but the other symptoms can be fully present.

What are the symptoms of a silent migraine?

Visual aura

Zigzag lines, flickering or shimmering lights, or a blind spot that spreads slowly over 5 to 30 minutes and then fades. Some people also have tingling or numbness that moves slowly up one arm or across the face.

Brain fog

This may be the most frustrating symptom. Thinking clearly becomes hard, finding words takes longer and your concentration is gone. Because nobody can see it, people say: "You look fine, you are still coming to the party, aren't you?" Brain fog can last from hours to a whole day.

Neck stiffness

A stiff neck is a classic migraine symptom that many people do not link to migraine. It feels more like overwork or a bad night. The stiffness usually passes when the attack is over.

Tiredness that does not add up

Not tired after a long day, but exhausted even though you slept normally. Even simple tasks feel heavy. This can happen the day before, during or after an attack.

Sensitivity to light and sound

Office lighting suddenly feels harsh, music in the shop sounds much louder, and bright sunlight makes you squint. This is typical of migraine, with or without headache.

Mood changes and stomach symptoms

Some people notice sudden irritability, low mood or anxiety, or the opposite: feeling flat. Nausea does not always mean vomiting; some people mainly feel "off" in their stomach, and some have constipation or diarrhoea during an attack.

Why is silent migraine so often missed?

A migraine diagnosis is based entirely on your history. There is no blood test, scan or biomarker for migraine. So if you tell a doctor "I have brain fog, a stiff neck and I am very tired" without a clear headache, not everyone thinks of migraine straight away.

Many people with silent migraine have seen several specialists. The GP says: "Your blood tests are normal, it is probably stress." Someone else suggests depression. Meanwhile, it was migraine all along.

How do I know if I am having a silent migraine?

A silent migraine usually follows a pattern:

• it builds up gradually rather than starting suddenly
• an aura spreads slowly over several minutes and passes within an hour; other symptoms last hours to a day
• it passes on its own, with or without treatment
• it comes back regularly, not just once
• the symptoms are neurological: visual changes, brain fog, tingling, nausea, sensitivity to light and sound

If this sounds like you, a silent migraine is likely. A first aura, or symptoms that start suddenly, should always be checked by a doctor.

Are silent migraines harmful?

A typical silent migraine passes completely and does not damage the brain. The symptoms are real, though, and can affect work, study and social life. You are not imagining it, and it is not psychological: it is literally happening in your brain, because migraine is an inherited brain condition.

Are silent migraines a risk factor for stroke?

Migraine with aura, including aura without headache, is linked to a small increase in the risk of stroke. The overall risk remains low, especially in younger people. Smoking and the combined contraceptive pill (which contains oestrogen) increase the risk further, so if you have aura, tell your GP before starting or continuing the combined pill, and consider stopping smoking.

What is the treatment for silent migraine?

Silent migraine is just as treatable as migraine with headache. Your options:

• The right diagnosis: this matters most. Once you know it is migraine, treatment options open up.
• Acute medication: triptans are the main acute medication for migraine attacks. Some people find they also ease symptoms such as brain fog and tiredness. Your migraine specialist will advise on when to take them.
• Preventive treatment: if attacks are frequent, prevention can reduce how often and how severely they happen. Options include the gepants atogepant and rimegepant, and the CGRP antibodies erenumab, fremanezumab and galcanezumab, which were developed specifically for migraine.
• A headache diary: this helps spot patterns and show that it really is migraine.

When to get urgent help

Call 999 or go to A&E straight away if you have:

• a sudden, severe headache that is the worst you have ever had
• weakness or numbness on one side of your body or face
• slurred speech or difficulty finding words that does not pass
• loss of vision that does not return
• a first aura after the age of 50
• a headache with a fever and a stiff neck

If you are worried but it is not an emergency, call NHS 111.

There is hope

Silent migraine is a recognisable form of migraine with effective treatments. Wondering whether your symptoms fit? Take the migraine test, read what migraine is, or see how to start with a migraine specialist online. We help you get the diagnosis and take back control.

This article was written by the medical team of The Migraine Clinic, an online clinic specialised exclusively in migraine.