What is Migraine Aura?

What is Migraine Aura?

Migraine aura refers to a collection of symptoms that many people experience before or during a migraine attack. These symptoms can affect your senses in many ways, and some people find it to be the most debilitating part of a migraine attack.

The most common aura symptoms are visual, which people often describe as flashing lights or blind spots. Aura can also affect your senses, speech, or motor function. 

This article can help you understand the symptoms, causes, and treatment of migraine with aura. Click the headings below to jump to a specific section.

What is migraine aura?

Migraine aura refers to a collection of symptoms that you might experience before or during a migraine attack. These symptoms can affect your vision, senses, or neurological function.

Aura affects 20-40% of people with migraine, but it isn’t necessarily a part of every attack (1, 2). 

Visual symptoms are the most common, affecting about 90% of people who have aura (3). Visual aura might include flashes of light, blind spots, or seeing ‘zig zag’ patterns. Sensory disturbances, such as tingling in your hand or face, are less common. The rarest aura symptoms are speech disturbances (i.e. aphasia).

Aura can be quite distressing, especially the first few times it happens. However, these symptoms don’t cause any lasting damage, and will go away on their own.

Abstract art interpretation of migraine aura
Credit: Priya Rama (via Nature Outlook)

Symptoms

The symptoms of migraine aura are highly variable. People can have very different experiences with aura, and even someone who has aura frequently may find that their symptoms change from attack to attack (2).

However, there are a few things that often characterise aura symptoms (3):

  • Symptoms will begin gradually, and continue to progress gradually for 5 minutes to one hour.
  • Aura symptoms are often positive. This means that the symptom is ‘added on’ to your senses – for example, flashing lights are more common than blind spots (4).
  • If you experience more than one aura symptom, they will usually occur in succession rather than happening simultaneously. This often starts with visual symptoms, then sensory, then speech-related.
List of visual symptoms of migraine aura
Source: Viana et al, 2019, Clinical features of visual migraine aura: a systematic review; and Charles, 2018, The Migraine Aura.
List of sensory and speech-related symptoms of aura

Aura symptoms do have some overlap with the signs of a stroke or transient ischemic attack. There are some differences, but the first time you experience aura it can be disconcerting. 

You should call a doctor or 000 if you have any of these symptoms for the first time, or if they change in frequency or severity. An aura diagnosis should always be confirmed by a medical professional to rule out any serious health issues.

Aura vs prodrome: what’s the difference?

Both a migraine aura and prodrome occur before the pain phase of a migraine attack. The prodrome typically occurs in the 4-72 hours before the headache phase begins.

Prodromal symptoms include:

  • Fatigue
  • Irritability
  • Difficulty concentrating
  • Neck or muscle stiffness
  • Sensitivity to light and/or sound
  • Food cravings
  • Trouble with speaking or reading
  • A general sense of being unwell

There are some similarities between aura and prodromal symptoms, such as problems with vision and speaking. But migraine aura is much more distinct and doesn’t last as long as the prodrome. An aura usually is the last phase before the pain phase of a migraine attack. Prodromal symptoms also usually affect the entire body, whereas aura symptoms are unilateral (affecting one side/area of the body).

What does migraine aura look like?

There are many different types of visual aura symptoms, and they can sometimes be difficult to describe. One research review identified up to 25 distinct visual symptoms, ranging from blurry vision to fractured ‘mosaic’ vision (4).

If you’re still confused about what visual aura actually looks like, you can watch the videos below. They depict a ‘scintillating scotoma’. This is a common visual symptom in which a flickering, blurred spot appears in your vision and moves outwards.

Many people have also used art as a way to document and share their experiences. Some have done this methodically, drawing the movement of a symptom across their visual field over time. Others have taken abstract approaches to express their aura symptoms.

Diagram of visual migraine aura
Drawing of visual migraine aura progression (source: Nature Outlook)
Abstract art representing migraine aura
Source: Migraine Again
Landscape painting with drawing representing scintillating scotoma.

Types of migraine aura

Migraine with brainstem aura

This aura type involves symptoms that originate from the brainstem, which is at the base of the brain. These symptoms include (5):

  • Difficulty speaking (dysarthria)
  • Dizziness/vertigo
  • Ringing in the ears (tinnitus) or partial hearing loss (hypacusis)
  • Double vision
  • Impaired coordination
  • Decreased level of consciousness

Brainstem aura is typically accompanied by classic aura symptoms such as flashing lights or pins and needles.

Diagram of the brain showing the brainstem

Hemiplegic migraine

Hemiplegic migraine is characterised by temporary weakness on one side of the body. Symptoms can range from weakness with numbness and tingling through to temporary paralysis in the arm and leg on one side of the body (6). 

This type of aura can be alarming because the symptoms are similar to stroke symptoms. But unlike a stroke, the symptoms of a hemiplegic migraine come on gradually and fully resolve once the migraine attack subsides. In comparison, the symptoms of a stroke come on instantaneously and people are often left with permanent weakness.

Hemiplegic migraine can be passed down genetically, referred to as Familial Hemiplegic Migraine, or the condition can happen without any family history – referred to as Sporadic Hemiplegic Migraine.

Retinal migraine

Migraine with retinal aura causes fully reversible visual disturbances in one eye, such as shimmering or flickering of vision, blind spots, or blindness. In migraine with retinal aura, the visual symptoms typically only occur in one eye (7). 

This is different to the more common type of visual aura that is experienced by many people with migraine. In the more common type, if you cover one eye, the visual change (e.g., black spot) will still be present when looking through the eye that remains open.

Image of person covering one eye

What causes migraine aura?

One of the mysteries in migraine research is understanding what causes these unusual symptoms, and how are they connected to migraine overall?

In general, aura could be caused by the same factors that trigger migraine attacks without aura. This includes things like stress, sleep disruption, dietary changes, hormones, and environmental factors. You can read our full article about managing migraine triggers to learn strategies to help you prevent migraine attacks.

In terms of migraine aura specifically, the most commonly accepted theory points towards cortical spreading depression (CSD) (1). 

CSD is a wave of atypical activity that moves across the brain, altering the function of brain cells and blood vessels. As this activity moves across the brain, it can shut down parts of the brain, explaining why visual aura may appear to travel across the visual cortex.

Diagram of cortical spreading depression
Source: J Olesen et al, 2009, Origin of pain in migraine: evidence for peripheral sensitisation.

It’s difficult to prove because CSD is incredibly hard to detect in humans with current imaging technology. However it is easier to observe in animal studies, and these studies have suggested a connection between migraine and CSD (2).

The relationship between aura and migraine pain is more complicated. About 20-40% of people with migraine experience aura – and even then, they won’t always have aura alongside every migraine attack. Other people have aura without any head pain at all (1). 

These inconsistencies make it hard to say for sure what happens in the brain during a migraine attack. Lots of mechanisms are involved in migraine pain, such as inflammation of certain nerves & blood vessels and altered neurotransmitter function. 

Ultimately, we haven’t identified one ‘magic key’ that unlocks the mystery of migraine. Hopefully, through continued research we can come closer to finding the answers, and maybe even finding a cure for this debilitating disease.

Diagnosis

You will receive a diagnosis for migraine with aura by seeing your general practitioner or neurologist. Migraine aura is diagnosed according to criteria in the ICHD-3 (International Classification of Headache Disorders), which is developed by the International Headache Society.

You will be diagnosed if you have at least two attacks that involve (3):

Graphic of a doctor
  1. One or more of the following fully reversible aura symptoms:
    1. Visual
    2. Sensory
    3. Speech and/or language
    4. Motor
    5. Brainstem
    6. Retinal
  2. At least three of the following six characteristics:
    1. At least one aura symptom spreads gradually over ≥5 minutes
    2. Two or more aura symptoms occur in succession
    3. Each individual aura symptom lasts 5-60 minutes
    4. At least one aura symptom is unilateral (on one side of your body)
    5. At least one aura symptom is positive
    6. The aura is accompanied, or followed within 60 minutes, by headache

If you need to find a neurologist, you can use our Doctor Directory to find a practitioner that specialises in migraine and headache.

Treatment & prevention

The treatment and prevention methods for migraine aura are similar to migraine without aura. Your migraine management strategies will depend on the severity and frequency of your attacks. Some options include:

Acute treatment

  • Over-the-counter medication (ibuprofen, panadol, etc)
  • Triptans (migraine-specific medication)
  • Anti-nausea medication
  • Staying in a dark room
  • Using a cold compress on your forehead or neck

Preventive treatment

  • SSRIs, beta-blockers, anti-epilepsy drugs
  • Calcitonin gene-related peptide (CGRP) monoclonal antibodies
  • Botulinum toxin (Botox)
  • Nerve stimulation devices

Lifestyle management

  • Keep a headache diary
  • Identify specific triggers & avoiding them when possible
  • Maintain a regular sleep schedule
  • Avoid stress

You can develop a migraine management plan with your doctor. Most doctors will recommend a combination of pharmaceutical treatment and lifestyle management. 

Preventive treatments are used when migraine attacks begin to significantly disrupt your day-to-day life. Typically, this will be when you have four or more migraine days per month (8). In other cases, you may have fewer attacks, but when they occur they are so disabling that it warrants being on a preventive treatment.

Most preventive medications are equally likely to work for patients with and without migraine aura. However one preventive medication – lamotrigine – is recommended specifically for people with visual aura (8). Some research has also suggested that low-dose daily aspirin can help prevent migraine with aura (9).

If you are taking acute medications, it is important to make sure you aren’t taking them too frequently as they can cause medication overuse headache. Simple analgesics (ibuprofen, panadol) should be used no more than 3-4 times a week, and triptans no more than 1-2 times a week.

Aspirin for migraine with aura

Several clinicians at the Migraine World Summit have suggested aspirin may be a useful preventive for those who experience migraine with aura. More evidence is required for broad recommendation in migraine prevention, preferably from at least one larger double-blind, placebo-controlled study.

An observational case series of 49 patients with migraine were given aspirin 80 mg daily. Aura frequency was reduced in 39 of the 42 cases (92%) and full cessation of auras in 20 (48%) (10). Another retrospective study of 203 patients with migraine with aura found 95 (47%) use aspirin and report a significant reduction in aura (from 36 to 22 minutes) and a “positive effect” (10).

Daily low-dose aspirin is readily available and well-tolerated. With further evidence it could play a significant role in migraine management and may be worth discussing as an option with your healthcare professional.

Further information & resources

Migraine aura is a complicated phenomenon. Learning more about these symptoms can help you better understand your migraine and inform your treatment approach.

Here are some related resources about migraine management & treatment that you may find useful:

 

References

  1. L Drew, 2020, A richer view of aura. DOI: 10.1038/d41586-020-02863-8
  2. A Charles, 2018, The Migraine Aura. DOI: 10.1212/CON.0000000000000627
  3. International Headache Society, 2018, 1.2. Migraine with aura. Retrieved from: https://ichd-3.org/1-migraine/1-2-migraine-with-aura/ 
  4. M Viana et al, 2019, Clinical features of visual migraine aura: a systematic review. DOI: 10.1186/s10194-019-1008-x
  5. International Headache Society, 2018, 1.2.2. Migraine with brainstem aura. Retrieved from: https://ichd-3.org/1-migraine/1-2-migraine-with-aura/1-2-2-migraine-with-brainstem-aura/ 
  6. International Headache Society, 2018, 1.2.3. Hemiplegic migraine. Retrieved from: https://ichd-3.org/1-migraine/1-2-migraine-with-aura/1-2-3-hemiplegic-migraine/ 
  7. International Headache Society, 2018, 1.2.4. Retinal migraine. Retrieved from: https://ichd-3.org/1-migraine/1-2-migraine-with-aura/1-2-4-retinal-migraine/ 
  8. Dr. Richard Stark. Migraine & Headache Awareness Week Webinar Presentation. Sept 2021. https://headacheaustralia.org.au/new-preventive-treatments/ 
  9. MB Anoaica et al, 2014, Acetylsalicylic Acid in Migraine with Aura Prevention – a Retrospective Study. DOI: 10.12865/CHSJ.40.02.08
  10. JM Hansen & A Charles, 2019, Differences in treatment response between migraine with aura and migraine without aura: lessons from clinical practice and RCTs. DOI: 10.1186/s10194-019-1046-4


Headache AustralianMigraine & Headache Australia is the only organization in Australia that aims to support the more than 5 million Australians affected by headache and migraine.
PLEASE HELP US BY DONATING TO OUR RESEARCH PROGRAM.