Migraine with aura

Migraine with aura, once called classic migraine, is a recurring headache that strikes after or at the same time as nervous system symptoms called aura. Aura symptoms usually last less than an hour. They can include flashes of light, blind spots and other vision changes that affect both eyes. Aura also can cause tingling in your hand or face. Sometimes people who have migraine with aura also experience muscle weakness or issues with speech and language. Visual aura symptoms are most common.

Treatments for migraine with aura and migraine without aura, once called common migraine, usually are the same. Treatments include medicines to prevent migraine with aura and those to stop the headache once it has started. Other treatments include relaxation techniques such as massage. You can try to prevent migraine with aura using self-care steps such as following a regular sleep and meal schedule and avoiding things that may trigger migraine.

Migraine aura symptoms include temporary visual or other disturbances. Aura symptoms 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 of when headache pain begins. It generally lasts less than 60 minutes. But aura can happen at the same time as the headache. Rarely, aura can happen without a headache following it. When this happens, it’s usually in people over age 50.

Visual symptoms

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

• Blind spots, also called scotomas, which sometimes are outlined by simple shapes such as a circle.
• 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:

• A tingling feeling in one hand or on one side of the face that may spread slowly along an arm or leg and may turn into numbness.
• Numbness or tingling of the tongue or mouth.
• Speech or language difficulty.
• Hearing ringing in the ears or other noises.
• Hearing loss.
• Inability to move part of the body.
• Muscle weakness.

If you regularly experience signs and symptoms of migraine with aura, keep a record of your migraine attacks and what you did to treat them. Make an appointment with your healthcare professional to discuss your headaches.

Even if you have a history of headaches, see your healthcare professional if the pattern changes or your headaches suddenly feel different.

See your healthcare professional 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 healthcare professional will need to rule out more serious conditions, such as a stroke.

Migraine with aura sometimes can be confused with a rare type of migraine called retinal migraine. Retinal migraines can cause similar symptoms such as vision changes, but these symptoms occur in one eye only. Vision changes and vision loss are temporary with retinal migraine, and many people don’t have a headache.

There are other potential causes of vision loss in one eye that should be examined by a healthcare professional, so it’s important not to assume this symptom means you have a retinal migraine.

There is evidence that migraine auras are due to electrical or chemical waves that move across the brain. This is called cortical spreading depression. The part of the brain where an electrical or chemical wave spreads determines the symptoms you might experience.

Electrical or chemical waves can occur in areas that process sensory signals, in speech centers or in 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. This wave also is thought to cause headache pain that typically follows aura.

Electrical and chemical waves can occur with typical functioning of the nerves and do not cause harm to the brain.

Migraine and migraine with aura share many of the same triggers. These include:

• Stress.
• Bright lights and loud sounds.
• Being around smoke or strong odors.
• Drinking too much alcohol, especially wine.
• Consuming too much caffeine.
• Some foods, including processed foods or those that have additives such as MSG.
• Too much or too little sleep.
• Menstruation and other hormonal changes.

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 also are more common in people assigned female at birth. This may be related to hormonal changes in people assigned female at birth.

People who have migraine with aura are at a mildly increased risk of stroke. Depression, anxiety and sleep issues also are more common in people with migraine, including migraine with aura.

Taking too many medicines to treat migraines can lead to another type of headache called medication overuse headache (MOH).

Your healthcare professional might diagnose migraine with aura based on your symptoms, your medical and family history, and a physical exam. To diagnose you with migraine with aura, your healthcare professional will look for a history of repeated headaches that include:

• Pain on one side of the head.
• Pain that pulses and throbs.
• Temporary visual disturbances or vision loss.
• Temporary hearing loss.
• Nausea.
• Sensitivity to light and sound.

There’s no specific test to diagnose migraine with aura.

If your aura isn’t followed by head pain, your healthcare professional 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 called an ophthalmologist can help rule out eye problems that might cause visual symptoms.
• Head computerized tomography (CT) scan. This X-ray technique produces detailed images of your brain. It usually is not needed to diagnose migraine. It may be used if your symptoms aren’t typical or there is an unusual finding during your exam.
• Magnetic resonance imaging (MRI). This diagnostic imaging procedure produces images of your internal organs, including your brain. It usually is not needed to diagnose migraine with aura. It may be used if your symptoms aren’t typical or there is an unusual finding during your exam.

Your healthcare professional might refer you to a doctor who specializes in nervous system conditions, called a neurologist. A neurologist can rule out brain conditions that could cause your symptoms.

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

Medicines for relief

Medicines 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, medicines that can be used to treat it include:

• Pain relievers. Pain relievers you can buy without a prescription include aspirin and ibuprofen (Advil, Motrin IB, others). Other medicines may be prescribed. When taken too frequently, these might cause medication overuse headaches (MOH) and possibly ulcers and bleeding in the gastrointestinal tract.

  Migraine relief medicines 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, these medicines 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. Zavegepant (Zavzpret) is a CGRP angonist in nasal spray form used to treat migraine and migraine with aura. 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 of these medicines include dry mouth, nausea and excessive sleepiness. Ubrogepant and rimegepant should not be taken with strong CYP3A4 inhibitor drugs.

• Opioid medications. Because opioids can be highly addictive and cause MOH, these usually should be avoided.
• 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 usually are taken with pain medicines.

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

Preventive medicines

Medicines taken regularly can help prevent frequent migraines, with or without aura. Your healthcare professional might recommend preventive medicines if you have frequent, long-lasting or severe headaches that don’t respond well to treatment.

Preventive medicine 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 medicines. These include beta blockers such as propranolol (Inderal, InnoPran XL, others) and metoprolol (Lopressor). Calcium channel blockers such as verapamil (Verelan) may help prevent migraines with aura if other medicines haven’t been effective.
• Antidepressants. A tricyclic antidepressant called 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 they can cause side effects such as dizziness, weight changes, nausea and more. These medicines are not recommended for people who are pregnant or are trying to get pregnant.
• Botox injections. Injections of onabotulinumtoxinA (Botox) about every 12 weeks help prevent migraines for some adults.
• Calcitonin gene-related peptide (CGRP) monoclonal antibodies. Erenumab-aooe (Aimovig), fremanezumab-vfrm (Ajovy), galcanezumab-gnlm (Emgality), and eptinezumab-jjmr (Vyepti) are newer drugs approved by the U.S. 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.
• CGRP antagonists. Also called Gepants, these medicines include atogepant (Qulipta) and rimegepant (Nurtec) and are approved for migraine prevention.

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

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 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.
• Keep a headache diary. Log when your headaches happen and what your day was like. Include your schedule, meals, mood and more. Loud noises, certain odors, foods, alcohol and other factors are common migraine triggers. If you learn what triggers migraines with aura for you, you can take steps to avoid those things.

If you’re having temporary visual or sensory disturbances, see your primary healthcare professional. In some cases, you may be referred to a doctor who specializes in the nervous system, called a 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. Include when they occurred, how long they lasted, and what triggered them. A headache diary can help your healthcare professional 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 healthcare professional.

For migraine with aura, some questions to ask your healthcare professional 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 healthcare professional 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?