Migraine with Aura – Symptoms, Causes and Treatment
Migraine with aura is a neurological condition characterised by recurring headache attacks preceded by reversible neurological symptoms such as visual disturbances.
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Migraine with aura is a neurological condition characterised by recurring headache attacks preceded by reversible neurological symptoms such as visual disturbances.
What is Migraine with Aura?
Migraine with aura is a subtype of migraine in which the characteristic headache is preceded or accompanied by transient neurological symptoms known as the aura. The aura is caused by a slowly spreading wave of neuronal and ionic changes across the brain cortex, a phenomenon called cortical spreading depression. Migraine is one of the most common neurological disorders worldwide, and approximately 25–30% of all migraine sufferers experience attacks with aura.
Causes and Risk Factors
The exact cause of migraine with aura is multifactorial and not yet fully understood. Contributing factors include:
- Genetic predisposition: Migraine tends to run in families, and several gene mutations have been identified, particularly in familial hemiplegic migraine.
- Neuronal hyperexcitability: The brains of migraine sufferers are more sensitive to stimuli such as light, noise, and stress.
- Hormonal fluctuations: Changes in oestrogen levels, for example during the menstrual cycle, can trigger attacks.
- Triggers: Sleep deprivation, alcohol, certain foods (e.g. aged cheese, red wine), weather changes, and emotional stress.
Symptoms
The Aura
The aura typically lasts 20–60 minutes and resolves completely. Common aura symptoms include:
- Visual disturbances: Scintillating scotoma (flashing lights, zigzag lines, blind spots) – the most frequent type of aura
- Sensory disturbances: Tingling or numbness, usually starting in the hand and spreading toward the face
- Speech disturbances (aphasia): Difficulty speaking or finding words
- Motor weakness: Rare, occurring in hemiplegic migraine
The Headache Phase
Following the aura – or sometimes occurring simultaneously – a unilateral, throbbing headache of moderate to severe intensity develops, lasting 4–72 hours. Common associated symptoms include nausea, vomiting, and sensitivity to light and sound.
Diagnosis
The diagnosis is clinical, based on the patient's medical history and symptom description. The International Headache Society (IHS) has established clear diagnostic criteria (ICHD-3). Imaging techniques such as MRI or CT are used to rule out other causes (e.g. stroke, tumour). A headache diary is helpful in identifying patterns and triggers.
Treatment
Acute Treatment
The following medications are used to treat an acute migraine attack:
- Triptans (e.g. sumatriptan, rizatriptan): migraine-specific agents acting on serotonin receptors
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or aspirin
- Antiemetics (e.g. metoclopramide) for nausea and vomiting
- For severe attacks: CGRP antagonists (gepants)
Preventive Treatment
For frequent or severe attacks, preventive therapy is recommended:
- Beta-blockers (e.g. metoprolol, propranolol)
- Antiepileptics (e.g. topiramate, valproate)
- Antidepressants (e.g. amitriptyline)
- CGRP monoclonal antibodies (e.g. erenumab, fremanezumab) – modern, highly effective biologics
- Non-pharmacological approaches: regular sleep, stress management, biofeedback, aerobic exercise
Special Considerations and Risks
Compared to migraine without aura, migraine with aura is associated with a slightly increased risk of ischaemic stroke, particularly in women who smoke and use combined oral contraceptives (oestrogen-containing). Affected individuals should discuss this risk with their healthcare provider.
References
- Headache Classification Committee of the International Headache Society (IHS): The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia, 2018.
- Goadsby PJ et al.: Migraine – Current Understanding and Treatment. New England Journal of Medicine, 2002; 346(4): 257–270.
- Diener HC, Holle-Lee D, Nägel S et al.: Treatment of migraine attacks and prevention of migraine. Deutsches Ärzteblatt International, 2019; 116(33–34): 557–564.
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