Migraine with aura

Overview

Migraine with aura (also called classic migraine) is a recurring headache that strikes after or at the same time as sensory disturbances called aura. These disturbances can include flashes of light, blind spots, and other vision changes or tingling in your hand or face.

Treatments for migraine with aura and migraine without aura (also called common migraine) are usually the same. You can try to prevent migraine with aura with the same medications and self-care measures used to prevent migraine.

Symptoms

Migraine aura symptoms include temporary visual or other disturbances that usually strike before other migraine symptoms — such as intense head pain, nausea, and sensitivity to light and sound.

Migraine aura usually occurs within an hour before head pain begins and generally lasts less than 60 minutes. Sometimes migraine aura occurs without headache, especially in people age 50 and older.

Visual signs and symptoms

Most people who have migraine with aura develop temporary visual signs and symptoms, which tend to start in the center of the field of vision and spread outward. These might include:

• Blind spots (scotomas), which are sometimes outlined by simple geometric designs
• Zigzag lines that gradually float across your field of vision
• Shimmering spots or stars
• Changes in vision or vision loss
• Flashes of light

Other disturbances

Other temporary disturbances sometimes associated with migraine aura include:

• Numbness, typically felt as tingling in one hand or on one side of your face that may spread slowly along a limb
• Speech or language difficulty
• Muscle weakness

When to see a doctor

See your doctor immediately if you have new signs and symptoms of migraine with aura, such as temporary vision loss, speech or language difficulty, and muscle weakness on one side of your body. Your doctor will need to rule out more-serious conditions, such as a stroke.

Causes

There is evidence that the migraine aura is due to an electrical or chemical wave that moves across the brain. The part of the brain where the electrical or chemical wave spreads determines the type of symptoms you might experience.

This electrical or chemical wave can occur in areas that process sensory signals, speech centers or centers that control movement. The most common type of aura is visual aura, which occurs when a wave of electrical activity spreads through the visual cortex and causes visual symptoms.

The electrical and chemical waves can occur with normal functioning of the nerves and do not cause harm to the brain.

Many of the same factors that trigger migraine can also trigger migraine with aura, including stress, bright lights, some foods and medications, too much or too little sleep, and menstruation.

Risk factors

Although no specific factors appear to increase the risk of migraine with aura, migraines in general seem to be more common in people with a family history of migraine. Migraines are also more common in women than in men.

Complications

People who have migraine with aura are at a mildly increased risk of stroke.

Diagnosis

Your doctor might diagnose the migraine with aura based on your signs and symptoms, your medical and family history, and a physical exam.

If your aura isn't followed by head pain, your doctor might recommend certain tests to rule out more-serious conditions, such as a transient ischemic attack (TIA).

Assessments might include:

• An eye examination. A thorough eye exam, done by an eye specialist (ophthalmologist), can help rule out eye problems that might be causing visual symptoms.
• Head computerized tomography (CT) scan. This X-ray technique produces detailed images of your brain.
• Magnetic resonance imaging (MRI). This diagnostic imaging procedure produces images of your internal organs, including your brain.

Your doctor might refer you to a doctor who specializes in nervous system disorders (neurologist) to rule out brain conditions that could be causing your symptoms.

Treatment

For migraine with aura, just as with migraine alone, treatment is aimed at relieving migraine pain.

Medications for relief

Medications used to relieve migraine pain work best when taken at the first sign of an oncoming migraine — as soon as signs and symptoms of a migraine aura begin. Depending on how severe your migraine pain is, types of medications that can be used to treat it include:

• Pain relievers. These over-the-counter or prescription pain relievers include aspirin or ibuprofen (Advil, Motrin IB, others). When taken too frequently, these might cause medication-overuse headaches, and possibly ulcers and bleeding in the gastrointestinal tract.

  Migraine relief medications that combine caffeine, aspirin and acetaminophen (Excedrin Migraine) may be helpful, but usually only against mild migraine pain.

• Triptans. Prescription drugs such as sumatriptan (Imitrex, Tosymra) and rizatriptan (Maxalt, Maxalt-MLT) are used to treat migraine because they block pain pathways in the brain. Taken as pills, shots or nasal sprays, they can relieve many symptoms of migraine. They might not be safe for those at risk of a stroke or heart attack.

• Dihydroergotamine (D.H.E. 45, Migranal). Available as a nasal spray or injection, this drug is most effective when taken shortly after the start of migraine symptoms for migraines that tend to last longer than 24 hours. Side effects can include worsening of migraine-related vomiting and nausea.

  People with coronary artery disease, high blood pressure, or kidney or liver disease should avoid dihydroergotamine.

• Lasmiditan (Reyvow). This newer oral tablet is approved for the treatment of migraine with or without aura. In drug trials, lasmiditan significantly improved headache pain. Lasmiditan can have a sedative effect and cause dizziness, so people taking it are advised not to drive or operate machinery for at least eight hours.

• Calcitonin gene-related peptide (CGRP) antagonists. Ubrogepant (Ubrelvy) and rimegepant (Nurtec ODT) are oral CGRP antagonists recently approved for the treatment of acute migraine with or without aura in adults. In drug trials, drugs from this class were more effective than placebo in relieving pain and other migraine symptoms such as nausea and sensitivity to light and sound two hours after taking it.

  Common side effects include dry mouth, nausea and excessive sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor drugs.

• Opioid medications. For people who can't take other migraine medications, narcotic opioid medications might help. Because they can be highly addictive, these are usually used only if no other treatments are effective.
• Anti-nausea drugs. These can help if your migraine with aura is accompanied by nausea and vomiting. Anti-nausea drugs include chlorpromazine, metoclopramide (Reglan) or prochlorperazine (Compro). These are usually taken with pain medications.

Some of these medications are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medications without first talking with your doctor.

Preventive medications

Medications can help prevent frequent migraines, with or without aura. Your doctor might recommend preventive medications if you have frequent, long-lasting or severe headaches that don't respond well to treatment.

Preventive medication is aimed at reducing how often you get a migraine headache with or without aura, how severe the attacks are, and how long they last. Options include:

• Blood pressure-lowering medications. These include beta blockers such as propranolol (Inderal, InnoPran XL, others) and metoprolol tartrate (Lopressor). Calcium channel blockers such as verapamil (Verelan) can be helpful in preventing migraines with aura.
• Antidepressants. A tricyclic antidepressant (amitriptyline) can prevent migraines. Because of the side effects of amitriptyline, such as sleepiness, other antidepressants might be prescribed instead.
• Anti-seizure drugs. Valproate and topiramate (Topamax, Qudexy XR, others) might help if you have less frequent migraines, but can cause side effects such as dizziness, weight changes, nausea and more. These medications are not recommended for pregnant women or women trying to get pregnant.
• Botox injections. Injections of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines in some adults.
• CGRP monoclonal antibodies. Erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality), and eptinezumab-jjmr (Vyepti) are newer drugs approved by the Food and Drug Administration to treat migraines. They're given monthly or quarterly by injection. The most common side effect is a reaction at the injection site.

Ask your doctor if these medications are right for you. Some of these medications are not safe to take during pregnancy. If you're pregnant or trying to get pregnant, don't use any of these medications without first talking with your doctor.

Stress management and lifestyle

When symptoms of migraine with aura start, try heading to a quiet, darkened room. Close your eyes and rest or take a nap. Place a cool cloth or an ice pack wrapped in a towel or cloth on your forehead.

Other practices that might soothe migraine with aura pain include:

• Relaxation techniques. Biofeedback and other forms of relaxation training teach you ways to deal with stressful situations, which might help reduce the number of migraines you have.
• Develop a sleeping and eating routine. Don't sleep too much or too little. Set and follow a consistent sleep and wake schedule daily. Try to eat meals at the same time every day.
• Drink plenty of fluids. Staying hydrated, particularly with water, might help.

Preparing for your appointment

If you're having temporary visual or sensory disturbances, see your family doctor. In some cases, you may be referred to a doctor who specializes in nervous system disorders (neurologist).

Here's information to help you get ready for your appointment.

What you can do

• Keep track of your symptoms. Keep a headache diary by writing a description of each incident of visual disturbances or unusual sensations, including when they occurred, how long they lasted and what triggered them. A headache diary can help your doctor diagnose your condition and track your progress in between visits.
• Write down key personal information, including major stresses or recent life changes.
• Write down questions to ask your doctor.

For migraine with aura, some questions to ask your doctor include:

• What's the likely cause of my symptoms?
• What tests, if any, do I need?
• Is my condition likely temporary or chronic?
• What treatments are available? Which do you recommend?
• I have other health conditions. How can I best manage them together?
• Are there dietary restrictions I need to follow?
• Are there written materials I can take with me or websites you recommend?

Don't hesitate to ask other questions you have.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, including:

• When did you begin having symptoms?
• What types of visual symptoms or other sensations do you have?
• How long do they last?
• Are they followed by a headache?
• If you have headaches, how often do you get them and how long do they last?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?