Migraine with aura

Symptoms

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.

Causes

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.

Complications

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).

Treatment

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.