If you’ve ever had a migraine attack that came with vertigo, ringing in your ears, slurred speech, double vision, or a strange sense that you were about to black out, you may have been told it was “just a bad migraine.” But there’s a specific, less common subtype that produces exactly this cluster of symptoms: Migraine with Brainstem Aura, historically known as basilar migraine or basilar-type migraine.
This post breaks down what this condition is, what the research says about it, and why so many patients and upper cervical providers believe the root of the problem sits in a place most doctors never examine — the craniocervical junction, where the skull meets the top of the neck.
What Is Migraine with Brainstem Aura?
The name has changed a few times over the decades. It was first described by Dr. Edwin Bickerstaff in 1961 as “basilar artery migraine,” based on a group of mostly adolescent girls who experienced ataxia, vertigo, tinnitus, dysarthria, and visual or sensory disturbances alongside their headaches. As imaging technology advanced and it became clear that the basilar artery itself wasn’t spasming the way researchers once assumed, the International Headache Society dropped the vascular name. By the third edition of the International Classification of Headache Disorders (ICHD-3), the condition was formally renamed Migraine with Brainstem Aura (MBA).
According to current ICHD-3 diagnostic criteria, a person must have a migraine with aura, plus at least two of the following fully reversible brainstem symptoms, with no motor weakness and no retinal symptoms:
- Dysarthria (slurred speech)
- Vertigo (a true spinning sensation, not simple dizziness)
- Tinnitus (ringing in the ears)
- Hypacusis (reduced hearing)
- Diplopia (double vision)
- Ataxia (loss of coordination not explained by sensory loss)
- Decreased level of consciousness
This is considered a rare presentation, affecting roughly 1.5% of people who have migraine with aura, and it most often first appears in adolescence or young adulthood. Because the symptom list overlaps so heavily with other neurological and inner-ear conditions, it’s also one of the more frequently misdiagnosed forms of migraine — sometimes mistaken for seizure disorders, vestibular disease, or even stroke.
Conventional neurology treats MBA the way it treats most migraine subtypes: as a primary disorder of brain excitability, involving cortical spreading depression and brainstem/trigeminovascular activation, managed with the standard migraine medication toolkit. That explains what is happening in the nervous system during an attack. It doesn’t fully explain why the brainstem becomes irritable in the first place, or why some people are far more prone to these attacks than others. That’s where a growing body of upper cervical research offers a compelling piece of the puzzle.
The Upper Cervical Connection
The upper cervical spine — the joint between the skull and the atlas (C1), and between the atlas and axis (C2) — is unlike any other region of the spine. It has to support the full weight of the head, allow for more rotation than any other joint in the body, and simultaneously protect the brainstem, the vertebral arteries, and the flow of cerebrospinal fluid (CSF) as they all pass through this narrow corridor. When this joint loses its proper alignment — whether from an old whiplash injury, a fall, poor posture, or repetitive strain — it doesn’t just cause neck pain. It can alter three interconnected systems that are directly implicated in brainstem-type migraine symptoms.
1. Blood Flow Hydrodynamics: The “Choke Point” Theory
Chiropractic neurologist Dr. Michael Flanagan published a widely cited paper describing the craniocervical junction (CCJ) as a potential “choke point” for both blood and cerebrospinal fluid moving between the cranial vault and the spinal canal. In his words, the CCJ is a narrow passage where everything entering or leaving the skull has to funnel through — arteries, veins, and CSF pathways alike. Flanagan’s paper connects faulty hydrodynamics at this choke point to a long list of neurological conditions, migraine included, through a shared mechanism: when misalignment, ligament laxity, or structural strain compress or distort this junction, blood flow and CSF circulation become inefficient, contributing to chronic ischemia (reduced blood flow), tissue congestion, and irritation of the very brainstem structures that generate the symptoms found in MBA — vertigo, tinnitus, double vision, and disturbed consciousness among them.
Upright posture and the constant motion of the neck only add to this strain over a lifetime, which is part of why symptoms so often develop gradually and worsen with age, injury, or postural stress rather than appearing overnight.
2. The Myodural Bridge
Just beneath the base of the skull, a set of small suboccipital muscles — most notably the rectus capitis posterior minor and major — physically attach to the dura mater, the tough membrane surrounding the brainstem and spinal cord, via a structure called the myodural bridge. This connection has been confirmed histologically, and researchers have even identified proprioceptive nerve fibers running directly through this bridge into the dura itself.
Functionally, this bridge is thought to help take up slack in the dura during head and neck movement, preventing the membrane from folding or compressing the brainstem and interfering with CSF flow around the cisterna magna. When the upper cervical joints are misaligned, these small muscles can become chronically tight, shortened, or strained. Because they’re mechanically tethered to the dura, that tension can transmit directly onto the brainstem’s covering — a plausible bridge (literally) between a neck problem and brainstem-level symptoms.
3. Proprioception and the Trigeminocervical Nucleus
The upper cervical spine contains one of the highest concentrations of proprioceptive nerve endings anywhere in the body — far denser than the rest of the spine. These receptors constantly feed the brainstem information about head position and movement. Critically, the sensory nerves from the upper three cervical segments (C1–C3) converge with the trigeminal nucleus caudalis — the same brainstem relay station that processes pain and sensory signals from the head and face, and the structure central to migraine pathophysiology.
When upper cervical joints are misaligned, the proprioceptive signal coming from that region becomes distorted or excessive. Because those cervical afferents share a processing hub with trigeminal (head/face) sensory input, abnormal signaling from the neck can spill over and sensitize the same brainstem circuitry responsible for migraine and its brainstem-type aura symptoms. This convergence is one of the more well-established anatomical links between the neck and headache disorders, and it’s a cornerstone of how upper cervical care is theorized to influence migraine frequency and severity.
Putting the Pieces Together
None of these three mechanisms works in isolation, and none of them replace the standard neurological understanding of migraine as a disorder of brain excitability. But taken together, they offer a physiologically plausible explanation for why the brainstem can become the epicenter of a migraine attack in some people:
- A misaligned craniocervical junction creates a hydrodynamic choke point, straining blood flow and CSF circulation to and from the brainstem.
- Chronic strain on the suboccipital muscles transmits tension through the myodural bridge directly onto the dura surrounding the brainstem.
- Distorted proprioceptive input from the upper cervical spine feeds into the same brainstem nucleus that processes head and face pain, lowering the threshold for a migraine attack and priming the brainstem symptoms characteristic of MBA.
For someone experiencing recurring vertigo, tinnitus, visual disturbances, or brainstem-type migraine symptoms, this is why an evaluation of upper cervical alignment is often a missing piece of the workup — one that looks upstream of the medication cabinet toward a structural, mechanical cause that conventional imaging and standard neurological exams aren’t designed to catch.
Article written by Dr. Drew Hall, Upper Cervical Chiropractor.
To locate an upper cervical chiropractor near you, visit www.neckwise.com.