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.^1,5 

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.

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. 

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. 

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.

Floaters

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.