Migraine With Aura

What is a migraine with aura?

A migraine is much more than just a headache. A common symptom some may experience is an aura - sensory disturbances that occur before or during the headache.

Read on to learn more about what an aura is, how to identify its symptoms and how to effectively manage the symptoms.

What is aura?

An aura is a group of neurological symptoms (related to the nervous system) which may be accompanied with a migraine attack.

Those with migraines may get migraines with or without aura symptoms. Up to a third of migraine sufferers experience aura symptoms which develop gradually and last between 5 and 60 minutes. The symptoms are usually temporary and wear off over time.

The most common aura symptoms are visual symptoms and can include:

• Flashing/flickering lights

• Blind spots

• Blurred vision

• Seeing coloured spots or lines

• Seeing zig zag patterns

Some patients may also experience a sensory aura. This starts as numbness/tingling on the lips or tongue, on only one side of the face. The sensation spreads to the cheek and possibly to the hand on that side of the body.

Another type is motor aura, where the arm or leg on the same side of the body go weak. This is less common, requiring investigation if experienced for the first time.

Some may also experience slurred or confused speech, known as a speech aura.

It is advised to avoid any activities that may be dangerous whilst you are experiencing aura.

What does migraine aura look like?

As every patient's migraine experience is unique, it's important to identify specific symptoms to ensure you get the right treatment.

Visual aura is the most recognisable form and can vary widely. Common descriptions include:

• Scintillating scotoma - starting as small flickering lights in the centre of your vision.

• Fortification spectrum - that looks like a cracked windscreen with shimmering edges or colourful, zig/zag lines.

• Tunnel vision or blind spots

Sensory aura begins as tingling or pins and needles in the hand which spread to the face, usually only on one side of the body.

Speech/language aura, also known clinically as dysphasia, can be alarming. Symptoms may be confused with the symptoms of a stroke and include:

• Difficulty finding words

• Slurred or confused speech

Motor aura is linked to hemiplegic migraines. Whilst rare, patients may experience partial weakness or paralysis on one side of the body. This requires urgent medical review to rule out a stroke.

When does aura occur?

An aura gradually occurs over a period of 5 minutes and can last up to an hour. Some may experience aura throughout the attack, with others experiencing symptoms after the headache has begun.

Migraine with aura is associated with a slight increased risk of stroke, particularly in those who:

• Smoke

• Have high blood pressure

• Take the combined oral contraceptive pill

Although increased, the overall risk linked to migraine is still very low.

Migraine With Aura vs Without Aura: Key Differences

The key differences between migraine with aura and without are highlighted below:.

Migraine Aura Without Headache (Silent Migraine)

A misconception is that migraines always involve intense throbbing headaches. However, some patients experience the symptoms of an aura without ever developing the pain that usually follows.

Known as an acephalgic migraine or silent migraine, these can be worrying, particularly for those who don’t usually suffer from migraines.

As the neurological disturbances (the visual changes, tingling, or speech issues) occur on their own, these can easily be mistaken for medical emergencies.

So what happens during a silent migraine?

Symptoms of a silent migraine include:

• Zigzag lines

• Flashing lights

• Blind spots

• Nausea

• numbness/tingling

These symptoms overlap with more serious conditions such as a stroke or transient ischemic attack (TIA). For this reason, it's important to know how to tell them apart.

For a silent migraine, symptoms usually occur gradually and last no longer than 60 minutes.

You should seek immediate medical attention, by calling 999 if:

• Symptoms occur instantly (like a ‘light switch’)

• You experience symptoms for the first time without a migraine history

• You experience muscle weakness or drooping on one side of the face/body

• Symptoms last longer than 60 minutes

What Triggers Aura Migraines?

Migraine triggers can be different for everyone. You may not experience all of the following triggers and you may have triggers which are not listed below. Many find that a change in routine can trigger a migraine.

Hormones - a change in your hormone levels, particularly oestrogen, has been linked to migraines. For women, approaching the next period can trigger menstrual migraines

Stress - one of the most commonly reported triggers for migraine. This is thought to be due to a hormone that is released when you are stressed.

Sleep - a lack of sleep or too much sleep,or a change in your routine may increase the risk of a migraine attack.

Caffeine - may trigger migraines in excess or if you don’t have enough. If you find caffeine is a trigger, gradually cutting it out is preferred over suddenly stopping.

Other triggers include:

• Skipping meals

• Alcohol

• Dehydration

• Weather changes

• Light, noise and smells

• Using a computer

• Exercise

• Specific foods such as chocolate or dairy

Treating Migraine With Aura

Treating a migraine with aura is slightly different to treating a normal headache. As the aura is a warning sign, an important factor in treatment effectiveness is the timing of medication.

Acute treatment - When to Take Treatment

When you take the treatment depends on the type of treatment you are taking.

Over-the-counter painkillers

Painkillers like paracetamol or ibuprofen should be taken as soon as possible during the aura phase. This makes sure they are absorbed and exerting their effect by the time the pain begins.

These painkillers can be purchased from local pharmacies and supermarkets.

Triptans

Triptans are a specific migraine treatment which narrow dilated blood vessels and block inflammatory chemicals in the brain.

If you take Triptans (sumatriptan, rizatriptan), these should be taken when the headache starts, and not during the aura phase. If taken too early, their effectiveness may be reduced for some.

Due to how they work, triptans are contraindicated and must not be used by anyone who has:

• Hemiplegic migraines - involving motor weakness/paralysis

• Migraine with brainstem aura - involving vertigo, double vision or imbalance

• Pre-existing heart conditions

Preventative treatment

For patients who cannot take triptans, or experience frequent migraines, a modern treatment, Vydura, may be recommended. This contains the ingredient rimegepant and is licensed as a preventative treatment.

This treatment does not affect blood vessels and so is a safer option for patients with underlying heart conditions or complex aura types.

Prevention isn’t just about reducing the headache, it can also reduce aura symptoms.

Other treatments commonly used for prevention include:

• Bisoprolol - a beta blocker originally used for blood pressure/anxiety

• Anticonvulsants - such as topiramate, though these can cause side effects like brain fog

• Antidepressants - like amitriptyline or venlafaxine are useful for those where sleep issues are also present.

In addition to prescription medication, many clinicians and neurologists suggest to make lifestyle changes. Doing so can avoid common triggers linked to changes in routine or stress such as:

• Irregular sleep

• Dehydration

• Hormonal changes

• Missed meals.

Stroke Risk and the Combined Pill

Migraine with aura is associated with a small increased risk of stroke.

The risk is higher in those who:

• Smoke

• Have high blood pressure

• Take the combined oral contraceptive pill

The combined oral pill contains both oestrogen and progestogen. Oestrogen is an effective contraceptive but it also increases the risk of blood clots.

Migraine with aura already slightly increases the risk of a stroke. Adding a treatment on top of this which can cause blood clots causes an additive stroke risk.

These patients are advised to switch to a progestogen-only pill (POP) as the blood clot risk is only linked to oestrogen, not progestogen. Suitable forms of contraceptives for women with migraines are detailed below:

Despite this, it is important to remember that the overall risk is low, especially in otherwise healthy individuals.