CGRP Inhibitors for Migraine

Calcitonin gene-related peptide (CGRP) inhibitors represent a new class of drugs uniquely designed to treat migraine. There are two types of CGRP inhibitors: monoclonal antibodies which are designed for migraine prevention, and gepants which can be used as both preventive and acute migraine therapies. Several options are available within both categories. While these treatments are not a cure for migraine disease, they have proven to be safe and effective.

What is CGRP?

CGRP is the acronym for calcitonin gene-related peptide. CGRP is a small molecule made up of 37 amino acids that is produced naturally by the body.1 CGRP is involved in body functions in the gut, the reproductive tract, and blood vessels.2

CGRP may be helpful in protecting against cardiovascular issues, such as high blood pressure and heart disease. For example, in the midst of a heart attack or a stroke, CGRP may be released to help prevent such an event.1

While CGRP is found in everyone and is helpful to some of our body functions, the effects of CGRP can also contribute to migraine attacks.

What is the role of CGRP in migraine?

CGRP is released into the body during the migraine process.18 CGRP affects the trigeminal nerve, which communicates pain and sensitivity to touch and temperature. It is released throughout the peripheral and central nervous systems during a migraine attack. When CGRP attaches to its receptors in the brain, it perpetuates the migraine process, leading to inflammation and headache pain.3 4 In patients who have chronic migraine disease, CGRP levels remain elevated during a migraine attack, as well as between attacks.19

Did You Know?

The trigeminal nerve is the largest of the 12 cranial nerves that connect the brain to the body. Specifically, the trigeminal nerve connects to sensory and motor functions in 3 areas:

  • upper part of the face, including the forehead, scalp, and upper eyelids
  • middle part of the face, including the cheeks, upper lip, and nasal cavity
  • lower part of the face, including the ears, lower lip, and chin, controlling the movement of muscles in the jaw and ear.20

The trigeminal nerve is involved in almost all migraine attacks.21 Read more about the trigeminal nerve’s role in migraine:

Clinical studies have shown that when CGRP is injected into the body it causes moderate to severe headaches in people who have not been diagnosed with migraine disease, and migraine-like headaches in people who have migraine disease.1 18 This information suggests that people with migraine disease may be particularly sensitive to CGRP.18

The initial development and studies of drugs that target and reduce the amount of CGRP in the body began in the late 1990s.18 The first CGRP inhibitors to prevent, reduce, and or treat migraine attacks were approved by the FDA in 2018.3

Did You Know?

Migraine medications that block CGRP may also be known as:

  • anti-CGRP medications
  • CGRP inhibitors
  • CGRP receptor antagonists
  • CGRP monoclonal antibodies for migraine
  • gepants

What are CGRP Inhibitors?

CGRP inhibitors generally fall into two classes of drugs: Monoclonal antibodies and receptor antagonists.3

Monoclonal antibodies

Monoclonal antibodies work by blocking the CGRP pathway. They are a preventive treatment due to the longer duration  they remain in the bloodstream.1 Monoclonal antibodies are FDA approved for migraine with and without aura.6

The following monoclonal antibodies work by binding to the CGRP molecule itself, “mopping up” the CGRP in the body.7 They are FDA approved for the preventive treatment of migraine in adults.

  • Fremanezumab (Ajovy) is self-administered as a subcutaneous injection every month or every 3 months, depending on dosage.8
  • Galcanezumab (Emgality) is self-administered as a subcutaneous injection every month for the preventive treatment of migraine. A different dosage is approved for the treatment of episodic cluster headache.9
  • Eptinezumab (Vyepti) is administered in the doctor’s office as a 30 minute intravenous infusion every 3 months. It is approved for the preventive treatment of migraine in adults.10

A fourth FDA approved option, erenumab (Aimovig), works by binding to the CGRP receptor, so that the CGRP cannot be activated and result in a migraine attack.7 Aimovig is self-administered as an injection every month, and is approved for the preventive treatment of migraine in adults.11


Gepants are small molecule CGRP receptor antagonists that bind to and block CGRP receptors. Gepants are generally marketed for acute migraine treatment due to the shorter length of time they stay in the bloodstream, but some gepants may be used daily as a preventive treatment.1 4 5 12 13

The following gepants are FDA approved for the acute treatment of migraine in adults:

  • Rimegepant (Nurtec ODT) is a disintegrating 75 mg single dose oral tablet. It is also approved for the preventive treatment of episodic migraine.14
  • Ubrogepant (Ubrelvy) is prescribed as a 50 or 100 mg oral tablet. A second tablet can be taken in 2 hours if the migraine pain returns. The maximum dose is 200 mg per day.13 It is approved for the acute treatment of migraine attacks with or without aura; it is not approved for the prevention of migraine headaches.15

A third option, atogepant (Qulipta) is FDA approved for the preventive treatment of episodic migraine in adults. It is prescribed as a daily 10 mg, 30 mg, or 60 mg oral tablet.16 At this time it is not FDA approved for acute migraine treatment.

Did You Know?

A key attribute of gepants is that they do not cause rebound headache (medication overuse headache).12  Learn more about rebound headache.


What are the side effects?

Side effects of the CGRP monoclonal antibodies include:

  • constipation11
  • high blood pressure11
  • injection site reactions, such as pain, redness, or swelling8 9 10 11

Side effects of gepants include:

  • constipation16
  • fatigue15 16
  • nausea14 15 16
Who is contraindicated?

CGRP inhibitors are generally well tolerated and can be used safely by patients who do not have an allergic reaction to the drug or its ingredients. 

Before taking the drug, patients should tell their healthcare provider about all medical conditions and medications, as some interactions may exist.

CGRP inhibitors have not been adequately studied for safety in pregnant women, unborn infants, or their presence and effect in human milk, milk production, or breastfeeding infants.13 19 Patients should tell their healthcare provider if they are pregnant, breastfeeding, plan to become pregnant, or plan to breastfeed.

Safety and effectiveness in children has also not been established.19 None of the CGRP inhibitors discussed in this article have been approved for the treatment of migraine in children.

How much relief can be expected?

In clinical trials, more than half of people found that their migraine days and/or severity of their migraine attacks dropped by 50% when using a CGRP inhibitor.4 Fortunately, about 70% of people see some level of improvement.17

Some people may need to take the medication for three to six months to achieve an optimal response.4 6 There is currently no method to predict who will have good results, and which drug within the treatment class will be the most effective.2 If a patient does not find relief on one CGRP inhibitor, or has not tolerated it due to side effects, it is advisable to try another drug.12

CGRP inhibitors can be an equally effective option regardless of whether you have:

  • Failed to see migraine improvement on one or dozens of other preventive therapies.
  • Been using or overusing acute medications.
  • Been newly diagnosed with migraine disease or have had migraine for a lifetime.


With a new class of medication such as CGRP inhibitors, there may be challenges for patients to access these treatments. Commercial insurance companies in the U.S. generally require failure of at least two, if not three, preventive medications from three different classes before providing prior authorization to cover these new medications. This is usually due to the high cost of the CGRP inhibitors.6 Without insurance coverage, a year of treatment with a CGRP inhibitor can cost a patient several thousand dollars.13

To assist patients in obtaining these medications, some drug companies offer programs that offer free trial doses, temporary coverage of medication, or copay assistance. These programs may not be available to patients who have government insurance.4


CGRP inhibitors are the first medications specifically designed for the prevention and treatment of migraine attacks. They have few side effects, and a high degree of efficacy in reducing migraine frequency and/or severity. While cost and insurance coverage of these new medications may pose a challenge for some patients, there are payment assistance programs available. CGRP inhibitors bring new hope to many patients who have struggled to find an effective migraine treatment.

Additional Resources

Links to outside organizations and articles are provided for informational purposes only and imply no endorsement on behalf of Migraine World Summit.


Ocular Migraine

What is Ocular Migraine?

Anyone who has ever experienced an ocular migraine can probably recall their very first episode. They might have been sitting at their desk, feeling perfectly normal, then suddenly started seeing flickering lights, zigzagging lines, or a rash of colorful, kaleidoscopic waves. To say that the experience can be alarming would be an understatement. The good news is: it’s not dangerous.

Some people experience these “light show” symptoms regularly, usually before the onset of a painful headache. Others experience the symptoms alone – without the accompaniment of a classic migraine headache. And some may have experienced them only once or twice, never to be repeated again.


Ocular migraine is a term commonly used to describe certain visual disturbances associated with migraine. The symptoms are varied and can include:

  • flashing lights, or kaleidoscope- or prism-like visual sensations
  • zigzagging lines
  • stars
  • blind spots or scotomas

The condition – a type of migraine with “aura” – can be disturbing, but symptoms are generally benign and most last less than an hour. 

Aura is a term that refers to sensations other than head pain that can accompany a classic migraine. Visual symptoms are the most common type of migraine with aura, though aura can affect other senses and cause symptoms ranging from numbness and tingling in various parts of the body, nausea and vomiting, or even altered motor and language skills. 

These visual disturbances usually affect both eyes and can occur with or without a headache. 

Approximately one-third of migraine patients will experience migraine with aura. Some may have only one or two in their life, others may have a couple a month, and some may have an aura with every attack. About 15% of individuals who experience aura have one with every attack.1

Terminology Confusion

The term “ocular migraine” is considered a misnomer, in that the visual disturbances associated with it occur in the brain, not in the eye or in the retina.  

Though many people – including some medical specialists – continue to use the term “ocular migraine” to refer to a migraine with visual disturbances, it is more accurate to refer to ocular migraine as “migraine with aura” or “migraine with visual aura.”

Ocular migraine is sometimes referred to as “retinal migraine,” and although some of the symptoms overlap, the two diagnoses are not the same. Retinal migraine is a different and much rarer type of migraine.

On occasion, ocular migraine is also called “visual migraine,” “ophthalmic migraine” or “eye migraine,” but these are vague, general terms that refer to any migraine displaying visual impairments. 

But ocular migraine, I don’t use that term at all, because it’s too confusing. I don’t know if the person is talking about retinal migraine or migraine phenomenon or migraine with aura, so we try to stick with migraine with aura and and get rid of ocular migraine or eye migraine, because it really isn’t specific. It’s kind of a slang term.2

What Causes Ocular Migraine?

Ocular migraine – or migraine with visual aura – is generally thought to be caused by electrical disturbances in the brain, triggered by a phenomenon called cortical spreading depression. This refers to electrochemical waves that spread slowly across the cortex, the outer surface of the brain. Most of the time, these disturbances occur in the occipital lobe, the part of the cortex that controls vision, causing visual symptoms.1,2

How Does Ocular Migraine Differ From Retinal Migraine?

Though the terms “ocular” and “retinal” migraine are frequently used interchangeably, the two are not the same. While both types of migraine generally involve unusual temporary visual phenomena, ocular migraine symptoms generally involve both eyes. Symptoms can occur with or without a headache.  

Retinal migraine is a very rare cause of temporary vision loss in one eye (monocular), and can be – but is not always – followed by a headache within an hour of the onset of symptoms. 

The transient vision loss experienced in retinal migraine can range from partial to full. Symptoms may include flashing lights and scintillating blind spots. 

A retinal migraine diagnosis is made only after excluding other possible causes of single eye vision loss. An eye doctor should be able to make the diagnosis after conducting a comprehensive eye exam with dilation, including a formal visual field exam.

Vision impairment is quite common during migraine, so it’s not surprising that they’re going to end up in an eye doctor’s office…

Ocular Migraine Triggers

Ocular migraine attacks can be triggered by the same symptoms that trigger other migraine attacks and vary from person to person. Common triggers include:

  • stress
  • weather (including excessive heat or barometric pressure changes)
  • alcohol (including red wine)
  • caffeine 
  • skipping meals
  • certain foods (including aged cheeses, or foods containing additives such as nitrates, MSG, or artificial sweeteners)
  • dehydration
  • family history of migraine
  • hormonal fluctuations
  • loud noises
  • bright lights, including sunlight
  • strong odors
  • lack of sleep

Additional triggers may include activities that involve:

  • eye strain
  • extended computer screen use
  • harsh lighting
  • long-distance driving

Which Specialist to See When Experiencing Visual Symptoms?

A person experiencing visual disturbances, such as flashing lights, zigzagging lines, or even blind spots may first go to an eye doctor, who can conduct a comprehensive eye exam with dilation and rule out other causes of the symptoms before diagnosing migraine. An ocular migraine diagnosis does not mean the symptoms are occurring in the eye or caused by some dysfunction of the eye. The visual activity is caused by electrical disturbances in the part of the brain that controls vision. These symptoms can occur with or without headache. Patients who experience these symptoms are generally referred to a neurologist for ongoing migraine management.

When to Seek Immediate Medical Attention

Because a number of migraine-related symptoms can affect vision, it is not always easy to determine which are unrelated, but persons experiencing the following should seek medical attention right away to rule out stroke or another diagnosis that could lead to irreversible vision loss:

  • Any significant change or increase in duration of usual visual symptoms.
  • New floaters or flashes of light or dark spots in one eye that do not go away within an hour. 
  • Episodes of temporary vision loss in one eye.
  • Vision loss that presents as darkness or complete blindness.
  • Experiences of tunnel vision or inability to see out of one side of one’s vision field.

Treatments for Ocular Migraine

Drugs that treat regular migraine symptoms may be used to treat ocular migraine attacks. These include over-the-counter pain relievers, including:

  • ibuprofen
  • acetaminophen
  • aspirin 
  • naproxen

Prescription medications that may be used to treat an ocular migraine include many of the same medications used to treat classic or common migraine attacks, such as:

  • triptans, such as sumatriptan (Imitrex) or rizatriptan (Maxalt)
  • ergotamine derivatives, such as DHE (dihydroergotamine)
  • CGRPs – calcitonin gene-related peptide receptor agonists/gepants (Nurtec, Ubrelvy)
  • ditans – lasmiditan (Reyvow)
  • prescription NSAIDS, such as diclofenac or celecoxib
  • anti-nausea medications
  • neuromodulation devices, such as Cephaly, Nerivio, or Gammacore

Whether an individual is using over-the-counter or prescription medication, early-onset treatment is more effective than waiting until after the migraine attack has had a chance to build up.

Migraine Prevention

Patients who experience more frequent visual aura symptoms may consider medications designed to prevent classic or common migraine, including:

  • antidepressants, such as amitriptyline (Elavil ), nortriptyline (Pamelor), or venlafaxine (Effexor)
  • blood pressure medications, such as beta blockers or calcium channel blockers
  • anti-seizure drugs, such as valproic acid (Depakene, Depakote) or topiramate (Topamax, Qudexy XR, or Trokendi XR)
  • monoclonal antibodies, such as erenumab (Aimovig), galcanezumab (Emgality), fremanezumab (Ajovy), eptinezumab (Vyepti)
  • gepants, such as atogepant (Qulipta), rimegepant (Nurtec ODT)
  • Botox

Other practices/treatments that may be helpful

  • Get regular exercise – any kind – including walking, swimming, bicycling.
    • Eat regularly – try not to skip meals.
  • Develop good stress management strategies.
  • Consider mindfulness practices, such as meditation, tai chi, yoga, etc.
    • Maintain a regular sleep pattern (7-9 hours per night).
    • Consider testing for apnea if sleep is frequently interrupted.
    • Ask your healthcare provider if supplements may be helpful.
    • Join a migraine support group for tips and fellowship.
  • Consider FL-41/tinted lenses, which help block color wavelengths that bother persons with light sensitivity.

Looking forward

Roughly one-third of people with migraine experience some kind of aura, and many of those experience some kind of visual aura. The symptoms can be unsettling, but they are generally benign. It is important to note that effective options are available to treat attacks and help prevent future ones, as discussed above.

While there is no cure for migraine, many new treatment and prevention options are now available – and more are in the pipeline. Work with an experienced healthcare professional to find what management techniques work best for you. And consider joining a migraine support group to help you on your healthcare journey.

Migraine With Aura

​​Migraine, and migraine with aura, is more than just a headache. In fact, for many people it’s not a headache at all. Bouts of vertigo, waves of nausea, vision loss, and the inability to speak or walk are just some of the symptoms that those with migraine with aura can experience.

What is Migraine With Aura? 

Aura occurs due to a spreading electrochemical event on the surface, or the cortex, of the brain. This electrochemical event spreads slowly, two to three millimeters per minute, across the cortex, and as this event progresses, the aura symptoms commence. 

Most of the time, 90% in fact, the aura begins in the occipital cortex which controls vision, explaining why patients often complain of hallucinations in their vision. They’ll see spots, sparks, stars, lightning bolts, or even colors or prisms that will grow. Oftentimes it starts in the periphery, but it can also begin in the center of the vision. Then it expands over a period of time. The International Headache Society classifies migraine with aura as having reversible symptoms that resolve within an hour. If it goes on longer than an hour, that’s called prolonged aura and is less common.15 

The duration of symptoms depends on which area of the brain the spreading electrochemical event is occurring. Some people may start to feel numbness in their tongue, in their face, in their hand, in their arm, or even in their leg. They may think they’re having a stroke. Sometimes people will develop a language aura, so they’ll not be able to find words, or express themselves properly. They may slur their speech, or they might not understand speech (also known as aphasia). The type of dysfunction experienced corresponds to the physical part of the brain involved during the migraine attack. There are different types of symptoms, but they usually happen for a short period of time, and should be fully reversible.

Approximately one third of migraine patients will experience migraine with aura. Among those with aura there is great variability. Some may have a couple of auras in their life, others may have a couple of auras a month, and others may have an aura with every single attack. Of those individuals with aura, about 15% will have an aura with every attack. 

Types of Migraine with Aura

1. Migraine with typical aura

Migraine with typical aura refers to the most common symptoms associated with aura such as numbness, weakness, trouble with language, and visual disturbances. In addition to this combination of symptoms there are other types of migraine with aura with their own set of symptoms although some overlap with typical aura is common. 

2. Migraine with brainstem aura

In migraine with brainstem aura, a distinct set of symptoms can be experienced and produced by the brainstem itself which sits underneath the hemispheres of the brain.

Individuals may experience double vision, slurred speech, unsteady gait, dizziness, vertigo, ringing in the ears, or tingling on both sides of the body. 

With all these symptoms an individual may have one, some, or all of them during a migraine attack.2

About 10% of those who experience migraine with aura will have migraine with brainstem aura. It’s more common than hemiplegic migraine, but it’s still not common.2

3. Hemiplegic migraine

Hemiplegic migraine can cause paralysis and/or weakness. The name “hemiplegic” comes from the fact that during the aura or the neurological symptoms that precede the migraine attack, the patient is weak on one side of the body hence the term “hemi” meaning half and “plegia” meaning weakness.

Clinicians should determine if patients are describing numbness when perhaps they actually mean weakness. For instance, Dr. Dodick, at the 2017 Migraine World Summit, commented, when someone says numbness, “What do you mean by that? Do you mean that there’s no sensation? Do you mean that it’s tingling and prickling, or do you mean that it’s actually clumsy and weak?” It’s a very important distinction.

 Hemiplegic migraine causes weakness, and that weakness can involve the face, the hand, the arm, the leg, or all of the above. When patients with hemiplegic migraine develop weakness on one side of the body, they will almost always have either a visual aura and a sensory aura, and sometimes a language aura. 

Symptoms may include:

  • tingling and numbness
  • visual illusion (visual aura) 
  • they may not really understand what you’re saying or have trouble processing information
  • they may have trouble speaking.2

 Hemiplegic migraine patients can present with hemiplegia, or weakness on one side of the body, which can mimic a stroke. See article about Migraine and Stroke.

Sometimes there’s a motor aura, where people will develop weakness on one side of their body and that can mimic a stroke as well. 

4. Retinal migraine 

There is a form of migraine called retinal migraine, which is truly in one eye, but it’s an extremely rare form of migraine and it’s very difficult to diagnose.3 

Some of the people who have been examined during what they call a retinal migraine actually have a vasospasm of their artery in their eye causing the visual phenomenon. It’s always in one eye and they can get a headache right behind their eye.

What about ocular migraine?

If patients are experiencing black holes in their vision, spots in their vision or the symptoms of aura without headache, they typically see an ophthalmologist or eye doctor. Fortunately, most eye doctors will recognize migraine and be able to distinguish it from ocular disease. 

Eye doctors may refer to this as “ocular migraine” but it’s not a problem in the eyes itself. Dr. Dodick at the 2018 Migraine World Summit, asked, “Remember the spreading electrochemical event in the occipital cortex of the brain producing those visual symptoms? So ‘ocular migraine’ is a misnomer, it’s not the eyes causing the problem, it’s the brain causing the problem. So we call it migraine with aura whether or not it’s accompanied by headache.”

“Eye migraine” or “ocular migraine” are commonly used to describe this type of migraine but they are technically vague and unclear and not terms used by headache specialists for diagnosis. A headache specialist will refer to the condition either as migraine with aura or retinal migraine – which is a rare condition. 

Migraine With Aura Symptoms

Let’s look at the four phases of migraine and see where the aura phase fits in.

The four phases of migraine are:

  1. Premonitory or Prodrome phase
  2. Aura
  3. Headache phase
  4. Postdrome phase

The premonitory phase refers to the symptoms that occur in the hours before pain begins. 

In the aura phase a variety of symptoms may occur more immediately before the headache phase, but may also overlap with the headache phase. 

The headache phase is the point at which a moderate to severe headache is experienced.  

The postdrome refers to the phase after the headache resolves. Symptoms experienced in this phase may outlast the headache for hours to days.4

Prodrome symptoms

Prodrome symptoms refer to pre-headache signs and symptoms. These include fatigue, yawning, nausea, thirst, irritability and needing to use the bathroom frequently. 

Sometimes symptoms that occur during the painful headache phase itself can occur during the prodrome such as sensitivity to light, sensitivity to sound, neck pain, depression, feeling down, changes in mood, changes in one’s ability to concentrate and to process information. 

You might think, “I’m just in a little bit of a fog today, I’m not firing on all cylinders,” but it could be a prodromal phase. So you can see why all of those things reflect a problem in the brain itself versus in the blood vessels. Blood vessels couldn’t possibly cause all of those symptoms.1

Cravings are another common feature of prodrome cited by patients. These are sometimes interpreted as triggers. Cravings for certain foods like chocolate or other processed foods that are eaten and then followed by an attack lead a person to believe it may be a trigger. That isn’t necessarily the case. It may simply be part of the prodrome. Where migraine is thought to begin in the brain is an area that’s responsible for appetite and could plausibly be causing these food cravings.4

Vomiting and nausea can occur in the prodrome phase but it usually occurs in the head pain phase as the attack has progressed. Oftentimes the nausea is associated with the intensity of the pain, so the worse the pain, the worse the nausea, the more likely you’ll vomit. Not always, but often they tend to track together, but patients can remain nauseated in the postdrome phase, after the head pain has disappeared. 

There’s overlap with these symptoms and phases. There are not always clear lines of division between each phase or its symptoms. 

Aura Phase

Visual symptoms

Visual symptoms are the most common characteristic during a migraine with aura. A visual aura is a discrete neurological event that causes disturbance in the vision. It often will start like a little flickering or kaleidoscopic, and then will build up and grow as it moves across an individual’s field of vision. They are often a warning sign preceding the head pain phase of the migraine.

Many people think something is wrong with their eye, but really it’s happening in the brain, and if they cover the eye that they believe has the problem, they can still see little zig-zaggy lines or spots from the other eye.

We know that this disruption is coming from the brain. We also believe that it is triggered by cortical spreading depression. This refers to an electrical disturbance in the brain.

There are other types of auras, such as dizziness or vertigo auras, or numbness around the face and hand followed by a headache, but the visual aura is the most common.3 

Other visual symptoms include blurred vision, blind spots (scotoma), and/or temporary loss of vision as part of their migraine with aura.

For both living with migraine with and without aura, visual sensitivity in between their attacks is common. This sensitivity extends beyond just light but includes visual sensitivity to stripes, flickering lights and lights that are moving. In those people who are vulnerable, peripheral movement in the visual field may sometimes even trigger a migraine. Bright lights could trigger a migraine. People with migraine, in general, are visually sensitive and this can continue between attacks.3

Sensory symptoms

Numbness or tingling are common sensory symptoms that can occur during the aura. 

Most of the time, people will experience numbness or tingling that begins in maybe a couple of fingers, or maybe the digits of the hand, and then it will gradually creep up to involve the hand, and then maybe move up to the arm. It can jump to the face and occur around the mouth. Sometimes it will go inside the mouth and involve the gums and the tongue. Sometimes it will involve the whole body.

People can also experience weakness during the aura phase. Weakness can occur in the arm or leg, and face drooping can also be associated with their attacks. 

Cognitive symptoms

People may be cognitively affected during a migraine attack. A recent study has shown that cognitive symptoms were the second most disabling symptoms behind the head pain itself.2

Brain fog is a common cognitive symptom. An individual might just feel off on a particular day and not really understand why they feel off. Particularly, if they have frequent migraine attacks. Even though they’re not experiencing a headache, they might normally associate that with headache, but it looks like that symptom clears up, that brain fog clears up when they’re effectively treated.

Dr. Dodick has been seeing this for many years, when a patient is effectively managed on a preventive regimen, they feel better. They feel better because they’re not having as many headaches. “Even when I’m not having a headache, I feel better. I feel like a cloud has been lifted, or a fog has been lifted.”2

Like many symptoms of migraine, they can occur alone or in combination with other symptoms. As you know, you don’t even need to have headache, to have migraine. Dr. Dodick refers to it like a wheel with multiple spokes, and each spoke is a symptom.

 Sometimes you’ll have one spoke. Sometimes you’ll have five spokes. Sometimes you’ll have all the spokes on the wheel. 

You can get dizziness, or vertigo associated with a typical migraine attack, which accompanies a headache, and sometimes not. It can occur in isolation or it can occur in conjunction with other migraine symptoms, like sensitivity to light and noise and nausea. 

Can you have a migraine without headache or an aura without headache?

Yes, it is possible, however it is rare to only ever have a migraine aura without headache. This type of migraine is referred to as acephalgic migraine attacks. 

Another term used to describe this type of migraine is silent migraine. It occurs in perhaps 3-4% of people living with migraine. 

Some of the people who have migraine headache and have a visual aura can sometimes only have the visual aura without their usual headache. This combination is more common.

Migraine With Aura Causes

There are different theories but the truth is scientists still don’t really know what causes migraine with aura. One risk factor is having one or two parents with migraine with aura. There is a genetic link.  We do know that it occurs in the brain after it is triggered.

After head trauma, we know that there can be massive changes in depolarization in the brain, but there are people sitting normally, having a depolarization in the brain. The cortical spreading depression seems to occur for no good reason.

There may be certain migraine triggers for some people that make them more susceptible, for instance if they haven’t slept enough. Altitude may play a role in making people more susceptible to aura. But the initiation point is not really known.

Migraine With Aura Diagnosis

Diagnosis is typically made by a clinician taking a history from the patient who describes their symptoms. Some clinicians may perform a physical exam to rule out other conditions. Scans and tests are not typically required but may be requested in certain cases. 

Migraine itself is defined by the International Headache Society criteria as a headache which can be of moderate to severe intensity. It can be on one side of the head or on both sides of the head, and it has certain features associated with it. 

The features, for example, include nausea and/or vomiting; light and sound sensitivity; and difficulty in moving. These symptoms are common with migraine without aura.

Migraine with aura often has those features as well, but has separate features that clinicians can diagnose from listening to patients tell them about visual symptoms of flashing lights, numbness or tingling in the face or hands, and trouble with articulation and understanding others’ speech.   

Migraine With Aura Treatment

We know that early intervention, not just in migraine but other headache disorders and other diseases, help to prevent the downstream effects. The prodrome or premonitory phase sets itself up as an ideal opportunity for early intervention, with treatments that are safe and well-tolerated.

If people recognize the premonitory or prodromal phase they may be able to more effectively prevent or reduce the downstream effects, the onset of the pain and all the other symptoms. 

Once the headache phase begins, many people will reach peak headache intensity within about 30 minutes, so there isn’t a large window of opportunity within which to intervene.2

Acute treatments are medications used to treat an oncoming migraine attack. These include:

  • pain relievers available over the counter, including acetaminophen, ibuprofen, naproxen, diclofenac, celecoxib oral solution, and aspirin
  • triptans such as sumatriptan or rizatriptan
  • ergotamine derivatives such as DHE (dihydroergotamine)
  • anti-nausea medications
  • gepants (Nurtec)
  • ditans (Reyvow)
  • devices (Cefaly, Nerivio, Gammacore)

Triptans are specifically designed to be taken when you have a migraine attack. 

“There was initially some suggestion to say that you should avoid triptans during an aura. There’s a myth there that it’s dangerous to take a triptan during aura because you’re going to cause a stroke.5 There’s no evidence for that. There was one — an older study — that suggested it wasn’t effective. Then there’s also been other studies that suggested it can be effective. So I actually tell people to take it as soon as they feel the onset of their migraine coming on. But different people may have different opinions on that. With regards to other drugs like nonsteroidal anti-inflammatory drugs — and again you take it as soon as possible, as soon as you get these symptoms.”

Triptans are contraindicated in patients with hemiplegic migraine. That’s based on an old hypothesis that the aura, which is the weakness, is due to a lack of blood supply to the brain, and Triptans can cause constriction of blood vessels. There isn’t a lot of research to support whether triptans are indeed safe or not so it’s best to avoid triptans in this group until there is more evidence and data to suggest it’s safe.2

Migraine With Aura Prevention

If people have frequent aura and migraine or migraine with aura, many of the same preventatives that we use for migraine without aura will work with migraine with aura. 

If attacks are so frequent that people are disabled by them, they should be on a preventive medication. People who experience migraine should probably talk to their doctors about what’s right for them, because not everything is going to work for everybody. 

I’ve found that baby aspirin is really good for aura. Sometimes aura without headache, to prevent that, and also to prevent migraine with aura. But you have to know whether your system can tolerate baby aspirin or not. And that should be a conversation between a person and their primary provider. 
I’ve also found calcium channel blockers can be very helpful. Things like Verapamil sometimes are very good for people with migraine with aura.
Dr. Kathleen Digre, past president of the American Headache Society

Other preventatives that are helpful preventing migraine with aura include: 

  • antidepressants, such as amitriptyline (Elavil)
  • blood pressure medications, like beta blockers or calcium channel blockers such as candesartan (Atacand), propranolol (Inderal), timolol (Timoptic)
  • anti-seizure drugs, such as topiramate (Topamax), valproate sodium (Depacon)
  • Calcitonin Gene Related Peptide (CGRP) monoclonal antibodies:
    • erenumab (Aimovig)
    • fremanezumab (Ajovy)
    • galcanezumab (Emgality)
    • eptinezumab (Vyepti)
  • Botox
  • neuromodulation devices

There’s some data to suggest that some medications may be helpful for aura. There’s some small studies on a drug called Lamotrigine which suggests that maybe that had some beneficial effect on aura. There’s a drug called Flunarizine which is used quite widely throughout Europe, and there’s again anecdotal evidence from a pediatric study that it was more effective in hemiplegic migraine groups, so maybe a bit more effective in aura.5 

If you’re light-sensitive, sometimes FL-41 or the tinted lenses can be really helpful in preventing migraine attacks, in-between attacks.

Polarized sunglasses are not considered a preventive for those with a light sensitivity unless used outdoors to help reduce glare. People can wear sunglasses outside, because it blocks the light on all wavelengths. The FL-41 and some of these light filters can block certain wavelengths, especially the blue wavelength that seems to be more bothersome to people indoors.

What about other visual phenomena noticed by people living with migraine?

Visual snow

There are some people with migraine who can also get other visual phenomena. For example, there’s an entity called visual snow. Visual snow is very different from an aura. Aura is a discrete neurological event that occurs, typically followed by the headache. Visual snow is a persistent visual phenomenon. It’s like little, tiny dots in the field of vision, like in the old TV sets showing a static snowy pattern. People see visual snow commonly and they can see through it. Their vision can be 20/20, but they continuously see these little visual dots. Some people have blobs of color that they constantly see.


Dr. Digre has seen people who feel like they see little things floating around in their vision. People with migraine can have floaters. Lots of people have floaters and people with migraine seem to notice those floaters a little bit more readily. Floaters can be seen easier on a blank wall or in the blue sky. 

Image recurrence

People with migraine also have other strange symptoms such as image recurrence. They can look at an object, and then they can look away and they might see the same object sitting next to them, and that’s called palinopsia. Or they can have their hand go in front of a target and they can almost see their hand trailing across space.

It’s these unusual visual phenomena that people with migraine are more prone to, that are so different from our normal visual world, which makes it challenging for patients to explain to an  ophthalmologist or eye doctor for example.3

Migraine aura later in life

What’s interesting about this aura is as people get older, sometimes they lose the headache but keep the aura, and sometimes that is called later-life migraine accompaniments. It’s still a migraine aura, but it doesn’t trigger the headache.3

White Matter Lesions Associated with Migraine with Aura

MRI scans in people with migraine with aura may show T2 hyperintensities which might be concerning for some who ask if they are lesions and what they mean.

These are white-matter lesions, and they do not cause dementia.6

A study done in the Netherlands took several hundred patients, some that have migraine with aura, and they compared them versus a research control group of healthy people. MRIs were conducted on their brains and they measured the dots. Nine years later they found those patients again and then re-measured the dots on the MRI, specifically looking to see if there were cognitive changes that would occur over time. They found that women were more likely to have these dots, but there was no effect on cognition or neurological effects. 

There’s actually data that shows that these white-matter lesions are not a cause for concern. We do not think that they’re causing any damage. 6

Patent Foramen Ovale and Migraine

Some people are born with an open passageway between the two top chambers of their heart called the atria. If this passageway is open it’s referred to as a patent foramen ovale (PFO). Learn more about the link between the PFO and migraine in this article.  

Risk of Stroke

Some patients are worried about the risk of stroke as they may have heard that migraine with aura is associated with an increase in risk. Typically the increase in risk is minimal. Learn more about migraine and stroke risk, in this article (coming soon).  

When to see a healthcare provider?

How to talk to them about migraine with aura

Here are a few tips to get the most out of your doctor visit if you suspect you may have migraine with aura:

  • Keep a record of your migraine attacks. How often do they occur? How long do they last?
  • Record what happens during your attacks including sensory disturbances. Do you experience a visual aura? How long does that typically last? Describe the symptoms you may experience such as zigzag lines, flashing lights, or any other classic migraine with aura symptoms. 
  • Tell the doctor what treatments you’ve tried already and ask him/her about both acute and preventive options for your migraine.
  • Another tip is to take a friend or family member with you to your appointment to help you remember questions you wish to ask and also to help you recall the answers provided. There’s a lot that happens in a relatively short period of time and if you’re in pain or tired or experiencing side effects from treatments it is easy to lose track of what is said. 

What to expect from your doctor?

It’s important to recognize that patients with migraine will end up in many different physicians’ offices, especially because one-third have visual symptoms. These symptoms will most likely take them to an ophthalmologist or optometrist.

Sometimes patients with migraine have well-formed visual aura, so it’s very clear what’s going on. But at least half of patients who have migraine without aura will have something wrong with their vision during an attack, such as blurred vision. They can’t quite explain it, they can’t see as clearly, their vision is not as crisp. Things appear blurred or indistinct or something is affecting their vision. Vision impairment is quite common during migraine, so it’s not surprising that they’re going to end up in an eye doctor’s office.

For migraine with or without aura, most people will be treated and managed by the primary care physician. Primary care doctors vary widely in their understanding and interest of migraine. Going to your appointment prepared and informed with questions and requesting a comprehensive treatment plan once a diagnosis is confirmed will help ensure you get the most of our visit.  

Bottom Line

Migraine with aura affects a significant proportion of people with migraine. Its symptoms can feel strange and unsettling and even mimic those of a stroke. But there are effective options to manage migraine and help prevent attacks. 

Tips for migraine with aura are similar to those with general migraine: 

  1. Review your lifestyle triggers.
  2. Ensure you have a regular sleep pattern.
  3. Make sure you’re not missing meals.
  4. Practice good stress management. 
  5. Treat early. There’s evidence that you shouldn’t wait for your migraine attack to build up before you treat it. An established migraine attack is less responsive to treatment than treating at the onset. If you’re going to treat it, treat it at the onset of the attack.
  6. Prevention isn’t just for chronic migraine. If you have more than six days of any migraine symptoms per month, consider prevention strategies to stop the migraine attack from occurring in the first place. 

While there is not yet a cure for migraine, it can be effectively managed and controlled. It takes time to learn how migraine affects you and which treatment options and management plans work best for you. Working in partnership with your health care professional is a critical part of your migraine care.

Testing Four Five Six

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Testing One Two Three

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Sample Post for Testing

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This is a h3 heading. It’s another example

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Callout Box Example

This is a sample callout box using the Inline Notice block. Layout is set to Border, border width is set to 4px.

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