From the Guidelines
Migraine with aura, not intractable, without status migrainosus is a specific type of migraine headache condition that can be diagnosed based on criteria including at least two attacks with fully reversible aura symptoms and headache within 60 minutes, as outlined in the International Classification of Headache Disorders (ICHD-3) 1. This diagnosis describes a migraine that includes aura symptoms (such as visual disturbances, sensory changes, or speech difficulties) that occur before or during the headache phase. The term "not intractable" indicates that the condition responds to treatment and is not resistant to standard therapies. "Without status migrainosus" means the migraine episodes do not last longer than 72 hours continuously.
Key Characteristics
- At least two attacks that fulfill criteria for migraine with aura
- Fully reversible aura symptoms, including visual, sensory, speech and/or language, motor, brainstem, or retinal symptoms
- Headache that occurs within 60 minutes of the aura symptoms
- Not better accounted for by another ICHD-3 diagnosis
Treatment and Management
Treatment typically involves acute medications like triptans, NSAIDs, or anti-nausea medications during attacks, and possibly preventive medications if episodes are frequent, such as atenolol, bisoprolol, metoprolol, propranolol, candesartan, topiramate, amitriptyline, flunarizine, sodium valproate, onabotulinumtoxinA, erenumab, fremanezumab, or eptinezumab 1.
Lifestyle Modifications
Lifestyle modifications such as identifying and avoiding triggers, maintaining regular sleep patterns, and stress management are also important components of managing this condition.
Underlying Mechanism
The underlying mechanism involves complex neurological processes including cortical spreading depression during the aura phase, followed by activation of the trigeminovascular system during the headache phase. The most effective approach to managing migraine with aura, not intractable, without status migrainosus involves a combination of acute and preventive treatments, as well as lifestyle modifications, as recommended in the diagnosis and management of migraine in ten steps 1.
From the Research
Definition and Characteristics of Migraine with Aura
- Migraine with aura is a type of migraine that is characterized by a fully reversible focal neurological phenomenon involving visual, sensory, speech, and/or motor symptoms that develops gradually and usually precedes the headache phase 2.
- Aura is characterized by gradual development, duration of each symptom no longer than one hour, a mix of positive and negative features, and complete reversibility 2.
- Visual aura is the most common type of aura, occurring in over 90% of patients 2.
Diagnosis and Treatment of Migraine with Aura
- The diagnosis of migraine with aura is based on the International Headache Classification Disorders III edition criteria 2.
- It is recommended to start non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin as soon as possible during the aura phase, not to treat the aura, but to avoid or to diminish the headache phase 2.
- In case of failure of NSAIDs or aspirin, it is recommended to use a triptan when the headache begins 2.
- The efficacy of sumatriptan in acute treatment of migraine with aura has been assessed in several studies, with mixed results 3, 4.
- Metoclopramide has also been investigated as a potential treatment for migraine with aura, with some studies suggesting it may be non-inferior to sumatriptan 5.
Differences between Migraine with and without Aura
- Migraine with aura is associated with a modest increase in the risk of ischemic stroke, although the etiology for this association remains unclear 6.
- The pathophysiologic, epidemiologic, and clinical evidence for similarities and differences between migraine with and without aura is still being researched 6.
- Some studies suggest that sumatriptan may be less effective as acute therapy for migraine attacks with aura compared with attacks without aura 4.
- However, other studies have found that inhaled dihydroergotamine (DHE) has similar efficacy for migraine attacks with and without aura 4.