We are often asked about migraine aura and its investigation and management. This advice is intended to be used to support clinical decision-making, as well as alongside the national Headache Pathway:
Migraine aura
Warning
Migraine aura describes the temporary neurological symptoms that may occur before or during migraine headache, or occasionally happen on their own.
Around a third of people with migraine experience aura, usually before or during the headache phase. The majority of aura symptoms (90%) are visual, but other types of symptoms can also occur and may include:
- Vertigo
- Disturbances of sensation
- Speech disturbances
- Motor and brain stem function (ataxia, diplopia) may all occur
Aura typically lasts between 5 to 60 minutes, however, it can sometimes last longer - in rare cases, up to 24 hours. Symptoms are usually positive (i.e. zigzag lines rather than loss of vision, or tingling rather than numbness).
Aura may be present:
- Always
- Sometimes
- Or never in people with migraine
Up to 40% of people with typical migraine report occasional isolated aura (i.e. without headache). Aura occurring alone without ever having headache is well recognised, if uncommon.
- Diagnosis is clinical and straightforward - especially with typical visual aura
- The symptoms tend to evolve over minutes (unlike Transient Ischaemic Attack (TIAs))
- Symptoms usually last longer than TIAs or focal seizures (which typically last a minute or 2 at most), which are the usual differentials.
- Aura is often dynamic - e.g. spreading or getting larger across the field of vision over minutes, or spreading up the arm into the face
- If one symptom starts (e.g. speech disturbance) as another (e.g. numbness/tingling) is improving, that is very suggestive of migraine
- Not usually - unless the features are atypical
- Sometimes migraine can be triggered by other neurological conditions, but only investigate if there are other persistent neurological symptoms or signs.
- Not usually
- Brain imaging is not usually required for typical migraine aura
Migraine aura can be managed without medication.
Consider:
- Identifying and avoiding potential triggers where possible
- Reducing caffeine intake
- Managing stress
- Improving sleep
- Diet etc
There are no effective symptomatic therapies for aura alone – the available symptomatic drugs are for headache and nausea. Base treatment decisions on whether there is a bad headache, not on the aura symptoms.
If there is an intrusive headache, consider standard migraine prophylaxis. If there is no intrusive headache, prophylaxis can still be considered, but with lower expectations of benefit. Check whether your patient wants medication or is seeking reassurance that migraine aura is not harmful.
Older patients may present with frequent or worsening migraine aura, which understandably causes concern for them and their GP, particularly around the risk of stroke. In most cases, patients are seeking reassurance that the symptoms are not dangerous. They can be told that this is a common issue, especially with ageing. There's no evidence linking worsening migraine aura with stroke.
In addition to considering migraine prophylaxis, there is limited non-randomised evidence to support a trial of Aspirin 75mg in this group. This may be worth trying if the symptoms are affecting daily life and no other effective interventions are available.