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Migraine with Aura

What is Migraine With Aura? 

Migraine with aura is a subtype of migraine characterized by neurological symptoms that appear before or during the headache phase. These symptoms, known as auras, are fully reversible and typically develop gradually over minutes, lasting up to an hour. Migraine with aura affects approximately 20%–30% of individuals with migraine. It is important to note that someone who experiences migraine with aura won’t necessarily have an aura alongside every migraine attack, they can also experience attacks of migraine without aura.

Symptoms Migraine with aura involves two main phases: the aura phase and the headache phase. The aura consists of temporary neurological disturbances that may include:

  • Visual symptoms: The most common type of aura, affecting over 90% of cases. This often presents as flashing lights, zigzag patterns, blind spots, or shimmering effects.
  • Sensory symptoms: Pins and needles that slowly spread across one side of the body, face, or tongue, sometimes followed by numbness.
  • Speech and language disturbances: Difficulty finding words or forming coherent speech (aphasia).
  • Motor symptoms: Weakness in certain muscles, which can last longer than other aura symptoms.
  • Brainstem symptoms: Dizziness, double vision, or coordination difficulties.
  • Retinal symptoms: Temporary vision loss or flashing lights in one eye.

The aura phase is followed by a headache, which shares the characteristics of migraine without aura:

  • Moderate to severe intensity.
  • Throbbing or pulsating pain.
  • Unilateral location (though it can sometimes affect both sides).
  • Worsens with physical activity.
  • Accompanied by nausea, vomiting, light sensitivity (photophobia), and sound sensitivity (phonophobia).

 

women with visual issues

Cortical Spreading Depression and Migraine With Aura 

A widely accepted theory for why migraine aura occurs is cortical spreading depression (CSD). CSD is a slow-moving wave of changes in brain activity that spreads across the surface of the brain, temporarily altering the function of brain cells and blood flow. This wave can trigger the sensory disturbances seen in aura and may also activate pain pathways involved in migraine. One key player in this process is calcitonin gene-related peptide (CGRP), a neuropeptide that causes blood vessels to widen and is a major target for migraine treatments.

Migraine With Aura vs Migraine Without Aura 

Both types of migraine share similar headache characteristics, but the primary distinction is the presence of aura symptoms. Aura symptoms serve as a warning sign in migraine with aura, whereas migraine without aura’s most distinctive phase is the headache phase. Despite this difference, the underlying mechanisms and treatment approaches for both types of migraine are similar.

Differences Between Migraine With Aura and Other Conditions 

Because aura symptoms can include visual, sensory, and speech disturbances, they can sometimes be mistaken for other neurological conditions such as transient ischemic attacks (TIAs) or seizures. However, migraine aura symptoms develop gradually, last between 5–60 minutes, and are fully reversible, distinguishing them from other serious conditions.

Migraine Phases 

Like migraine without aura, migraine with aura follows a sequence of phases:

  1. Prodrome: Occurs hours or days before the headache and may include mood changes, fatigue, neck stiffness, or food cravings.
  2. Aura: Neurological symptoms that develop gradually and resolve within an hour.
  3. Headache Phase: The main migraine attack, accompanied by pain and associated symptoms.
  4. Postdrome: After the headache subsides, individuals may experience fatigue, confusion, and difficulty concentrating.

Subtypes of Migraine With Aura 

Several subtypes of migraine with aura exist, including:

  • Silent Migraine (Migraine Aura Without Headache): In this subtype, aura symptoms occur without the headache phase, which can make it challenging to recognize as a migraine disorder.
  • Hemiplegic Migraine: A rare form of migraine with aura that includes temporary motor weakness or paralysis on one side of the body, often accompanied by other aura symptoms such as visual disturbances or speech difficulties.

Treatment of Migraine With Aura 

Managing migraine with aura involves similar treatment strategies to migraine without aura, including medications and lifestyle modifications.

  • Medications:
    • Acute medications: 
      • Over-the-counter pain relievers such as ibuprofen e.g. nurofen, aspirin, or acetaminophen e.g. panadol.
      • Triptans, which are prescription medications specifically designed to relieve acute migraine symptoms.
      • Nausea medications e.g. stemetil, ondansetron. 
    • Preventative medications such as: 
      • Beta blockers.
      • Antidepressants.
      • Anti-epileptic medications.
      • Calcium channel blockers.
    • Injections:
      • Botox.
      • CGRP antibodies e.g. Emgality, Ajovy. 
  • Lifestyle Modifications:
    • Maintaining a regular sleep schedule.
    • Identifying and avoiding migraine triggers such as bright lights, certain foods, stress, dehydration.
    • Engaging in regular physical activity while avoiding excessive exertion.
    • Undergo physical therapy e.g. physiotherapy, osteopathy, to decrease muscle tension and joint stiffness in the neck, jaw, shoulders, and upper back.
    • Staying hydrated and consuming balanced meals.
    • Applying ice packs to the head or neck during an attack to help alleviate pain.
    • Reducing sensory stimulation during an attack by resting in a dark, quiet room and limiting exposure to screens or loud noises.

The more serious migraine subtypes – brainstem, hemiplegic, vestibular, abdominal, and retinal migraine – are all variants of migraine with aura. They can also occur with or without headache.

Managing aura can be difficult, as there aren’t really any treatments for aura. Many medications like triptans usually take longer to work than aura’s duration, so most people don’t take any as-needed medication. Others, however, may find that associated symptoms like nausea and sensitivity to light and sound will improve if treated. 

Some small studies and case reports suggest the use of magnesium and aspirin may be helpful, or for people with prolonged aura, there have been some treatment attempts with intranasal ketamine. These, however, are very small studies, and this is very much an off-label use. There are few specific studies looking at CGRP and aura, but anecdotally many have found the CGRP preventatives prevent the entire attack, including aura, so may be a worthwhile consideration.

Migraine with aura can be distressing, but understanding its symptoms and triggers can help individuals manage their condition more effectively. If you experience migraine attacks, consult a healthcare provider for evaluation and personalized treatment options.

Read more about migraine with aura from the Migraine Trust or the American Migraine Foundation.

 

Tammy Migraine aura Canberra, ACT

For as long as I can remember a headache was never a simple thing for me. Dizziness and nausea led to vomiting from a headache which seemed to be affected by light and sound. As a child, I hated it. Then at age 18, they evolved from there, causing the auras, the nerve ending shakes the tingling in my arms and on my tongue, accompanied with everything else beforehand.

Useful links:

Factsheet: Migraine Aura

  • Clinically reviewed by Dr Bronwyn Jenkins (BMed FRACP)

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