What Is a Migraine Aura?
A migraine aura is a set of temporary neurological symptoms that develop in the period before or during a migraine headache. Aura symptoms reflect temporary disruptions in specific areas of the brain and resolve completely without causing permanent damage in the vast majority of cases.
How Aura Develops?
- Aura is caused by a phenomenon called cortical spreading depression (CSD), a slow wave of electrical hyperactivity followed by suppression (reduced activity) that spreads across the brain's outer layer (cortex) at a rate of approximately 3 to 5 mm per minute
- Cortical spreading depression activates the trigeminal nerve (the main pain pathway in migraines) and triggers the release of inflammatory chemicals that cause migraine head pain
- Aura symptoms develop gradually over 5 to 20 minutes as the wave of cortical spreading depression moves across different brain regions
- Each aura symptom reflects which brain region the wave is passing through at any given moment
What Are the Symptoms of Migraine With Aura?
Aura symptoms are categorized by the type of neurological disturbance involved. A single migraine attack may involve one or more types of aura simultaneously or in sequence.
Visual Aura Symptoms
Visual aura is the most common type, affecting approximately 90% of people who experience aura, according to the American Migraine Foundation (2022).
- Zigzag lines or shimmering arcs of light (scintillating scotoma) that expand slowly across the visual field
- Flashing or flickering lights
- Blind spots (scotoma) in the central or peripheral vision
- Tunnel vision or temporary partial vision loss
- Geometric patterns or kaleidoscope-like visual disturbances
Sensory Aura Symptoms
- Numbness or tingling (pins and needles) typically starting in the hand or fingers and spreading up the arm toward the face
- A sensation of pins and needles moving slowly from one body part to another over several minutes
- Sensory symptoms are fully reversible and typically resolve within 60 minutes
Speech and Language Aura Symptoms
- Difficulty finding words or speaking clearly (aphasia)
- Slurred or confused speech
- Difficulty understanding spoken or written language in some cases
- Speech aura symptoms are less common and can be alarming as speech and language disturbances closely mimic stroke symptoms
Motor Aura Symptoms
Motor aura involves muscle weakness and is associated specifically with hemiplegic migraine, a rare subtype of migraine with aura.
- Temporary weakness or heaviness on one side of the body
- Difficulty coordinating movement on the affected side
- Motor aura symptoms can last longer than other aura types, sometimes persisting for several hours
Brainstem Aura Symptoms
Brainstem aura (previously called basilar migraine) involves symptoms originating from the brainstem rather than the cortex.
- Double vision (diplopia)
- Difficulty with balance and coordination (ataxia)
- Ringing in the ears (tinnitus)
- Decreased level of consciousness in rare cases
- Brainstem aura is rare and requires medical evaluation to rule out other similar conditions.
What Causes Migraine With Aura?
Neurological Causes
- Cortical spreading depression: The primary neurological mechanism behind aura, involving a wave of electrical hyperactivity followed by suppression spreading across the brain cortex
- Trigeminal nerve activation: Cortical spreading depression activates the trigeminal nerve, triggering the release of inflammatory neuropeptides (pain-signaling chemicals) including CGRP (calcitonin gene-related peptide)
- Genetic factors: Migraine with aura has a strong hereditary component. First-degree relatives (parents, siblings) of people with migraine with aura are four times more likely to experience the condition, according to a study in Brain (2021)
Common Triggers for Migraine With Aura
- Hormonal fluctuations, particularly estrogen drops around menstruation
- Sleep deprivation or irregular sleep schedules
- Stress and emotional upheaval
- Bright or flickering lights and visual stimulation
- Certain foods including aged cheeses, red wine, and MSG (monosodium glutamate)
- Dehydration and skipping meals
Migraine With Aura vs Migraine Without Aura
Health Risks Associated With Migraine With Aura
Stroke Risk
Migraine with aura is associated with a modestly increased risk of ischemic stroke (a stroke caused by a blood clot), particularly in women.
- Women under 45 with migraine with aura have approximately twice the stroke risk of women without migraines, according to a meta-analysis in the British Medical Journal (2021)
- The stroke risk is significantly amplified by smoking and the use of estrogen-containing contraceptives
- Women with migraine with aura are strongly advised to avoid estrogen-containing contraceptives and smoking, according to the WHO (2023)
Cardiovascular Risk
- People with migraine with aura show a modestly increased risk of cardiovascular events including heart attack and atrial fibrillation (an irregular heart rhythm)
- The absolute risk remains low in otherwise healthy individuals but warrants discussion with a doctor, particularly in people with additional cardiovascular risk factors
How Is Migraine With Aura Treated?
Acute Treatment During an Attack
- Take acute migraine medication such as triptans or NSAIDs (non-steroidal anti-inflammatory drugs) at the first sign of aura for the best response
- Move to a quiet, dark room and rest during the aura and headache phases
- Apply a cold compress to the forehead or neck to reduce pain intensity
- Stay hydrated by sipping water slowly if nausea is present
Medications for Acute Treatment
- Triptans such as sumatriptan and rizatriptan are the most effective acute treatments for migraine with aura, though triptans should be used with caution in hemiplegic migraine and brainstem aura
- NSAIDs such as ibuprofen and naproxen sodium are effective for mild to moderate attacks
- CGRP antagonists (gepants) such as ubrogepant are a newer class of acute medications that block the CGRP pathway involved in migraine pain
Preventive Treatment
Preventive treatment is recommended when migraine with aura attacks occur more than 4 days per month or significantly impact daily functioning.
- Beta-blockers such as propranolol reduce the frequency of aura and headache attacks
- Antiepileptic medications such as topiramate and valproate reduce cortical spreading depression and migraine frequency
- CGRP inhibitors such as erenumab and fremanezumab are highly effective preventive options with strong clinical evidence
- Magnesium supplementation (400 to 600 mg daily) has evidence for reducing aura frequency and is widely recommended as a first-line supplement
When Should You See a Doctor?
Seek immediate medical attention if:
- Aura symptoms are experienced for the first time, particularly if accompanied by severe headache, confusion, or weakness
- Aura symptoms last longer than 60 minutes or do not fully resolve
- One-sided weakness, speech difficulty, or vision loss occur suddenly without a prior history of aura
- Aura occurs without any headache following it
- Migraine with aura frequency increases significantly or symptoms change in character
Conclusion
Migraine with aura is a distinct neurological subtype affecting 25 to 30% of people with migraines. Aura symptoms, including visual disturbances, sensory changes, and speech difficulties, are caused by cortical spreading depression, a wave of electrical activity spreading across the brain. Aura-related migraine has a higher risk of ischemic stroke, especially in women who smoke or use estrogen-containing contraceptives, even though aura symptoms are usually completely reversible.
The best ways to lessen the impact of migraine with aura on day-to-day living are early detection of aura symptoms, timely acute treatment, and appropriate preventive management under the supervision of a neurologist.
