What is a migraine with sensory aura?

Migraine with Sensory Aura

Migraine with sensory aura is a subtype of migraine with aura characterized by fully reversible sensory symptoms—typically unilateral paresthesia (pins and needles) and/or numbness—that spread gradually over at least 5 minutes, usually in the face or arm, and last 5-60 minutes before or during the headache phase. 1

Clinical Characteristics

Sensory aura occurs in approximately 31% of individuals who experience migraine with aura, making it the second most common aura type after visual aura (which occurs in >90% of cases). 1

Key Diagnostic Features

The sensory symptoms must meet specific criteria to qualify as migraine aura 1, 2:

• Gradual spread: The paresthesia or numbness develops progressively over ≥5 minutes, distinguishing it from sudden-onset conditions like transient ischemic attack (TIA) 1
• Duration: Each sensory symptom lasts 5-60 minutes 1, 2
• Unilaterality: The sensory symptoms are typically one-sided, affecting the face, arm, or both 1
• Positive and negative features: Patients experience both "pins and needles" (positive symptoms) and numbness (negative symptoms) 1, 3
• Complete reversibility: All symptoms resolve completely without permanent neurological deficit 1, 3

Temporal Relationship to Headache

• The sensory aura is typically accompanied by or followed within 60 minutes by headache 1, 2
• When multiple aura symptoms occur, they usually follow in succession: visual symptoms first, then sensory, then speech disturbances 1, 3
• However, other sequences can occur, and sensory aura may occasionally appear without preceding visual symptoms 4, 5

Diagnostic Criteria

To diagnose migraine with sensory aura, patients must have at least 2 attacks meeting the following 1, 2:

• One or more fully reversible sensory aura symptoms
• At least 3 of these 6 characteristics:
  • At least one aura symptom spreads gradually over ≥5 minutes 1
  • Two or more aura symptoms occur in succession 1
  • Each individual aura symptom lasts 5-60 minutes 1
  • At least one aura symptom is unilateral 1
  • At least one aura symptom is positive (e.g., pins and needles) 1
  • The aura is accompanied or followed within 60 minutes by headache 1
• Not better accounted for by another diagnosis 1

Critical Differential Diagnosis

The most important distinction is between migraine sensory aura and TIA, as both can present with unilateral sensory symptoms 1:

• Migraine aura: Symptoms spread gradually (≥5 minutes), occur in succession, and have a "marching" quality 1
• TIA: Symptoms have sudden, simultaneous onset with maximal deficit at onset 1

Red Flags Requiring Emergency Evaluation

Investigate for TIA or stroke if the patient presents with 3:

• Sudden onset of sensory symptoms (not gradual)
• Simultaneous neurological symptoms (not successive)
• Symptoms corresponding to a specific cerebral vascular territory 3
• First-time aura presentation in a patient without prior migraine history 3
• Aura duration >1 hour 3
• Late onset of aura (new aura symptoms in older adults) 3
• Dramatic increase in aura attack frequency 3

Pathophysiology

The underlying mechanism is cortical spreading depression (CSD), a wave of neuronal and glial depolarization that spreads across the cerebral cortex at 2-3 mm/minute, corresponding to the gradual development of sensory symptoms 3, 6. This explains the characteristic "marching" pattern of paresthesia from one body region to another.

Clinical Implications

• Patients can have both migraine with aura and migraine without aura—both diagnoses should be made when applicable 1, 7
• Sensory aura may occur with or without visual aura in the same patient 4
• Rare cases involve multiple sensory modalities including auditory and olfactory disturbances 4
• Women with migraine with sensory aura should avoid combined hormonal contraceptives due to significantly increased stroke risk 3