Symptoms of Migraine with Aura
Migraine with aura presents with fully reversible neurological symptoms—most commonly visual disturbances that develop gradually over at least 5 minutes, last 5-60 minutes, and are typically followed by headache within 60 minutes. 1
Core Aura Symptoms
The aura phase consists of one or more of the following fully reversible symptoms 1:
- Visual symptoms (most common, occurring in >90% of cases) 2, 3
- Sensory symptoms (hemisensory disturbances, pins and needles, numbness) 1
- Speech and/or language disturbances (aphasic symptoms) 1
- Motor symptoms (weakness, as in hemiplegic migraine) 1
- Brainstem symptoms (dysarthria, vertigo) 1
- Retinal symptoms (monocular visual disturbances) 1
Visual Aura Characteristics
Visual aura is the hallmark symptom and includes 3, 4:
- Scintillating scotoma (most common type) 3
- Zigzag lines or fortification spectra 3
- Flashing lights, stars, or phosphenes 5
- Blurred vision 3
- Tunnel vision 3
- Visual distortions 5
Temporal Pattern of Symptoms
The aura follows a characteristic time course 1:
- Gradual onset: Symptoms spread gradually over ≥5 minutes (this distinguishes aura from stroke/TIA, which has sudden onset) 1
- Sequential progression: When multiple aura symptoms occur, they typically follow in succession (visual → sensory → aphasic) 1, 2
- Duration: Each individual aura symptom lasts 5-60 minutes 1
- Unilateral presentation: At least one aura symptom is typically unilateral 1
Associated Headache and Migraine Symptoms
Contrary to traditional teaching, headache and other migraine symptoms are present during the aura phase in the majority of patients (73%) 6:
- Headache during aura: 73% of attacks have headache present during aura, with 54% meeting migraine criteria within the first 15 minutes of aura onset 6
- Nausea: Present in 51% during aura 6
- Photophobia: Present in 88% during aura 6
- Phonophobia: Present in 73% during aura 6
Diagnostic Criteria Requirements
For formal diagnosis, at least two attacks must fulfill the following 1:
- At least three of six characteristics must be present: gradual spread over ≥5 minutes, two or more symptoms in succession, each symptom lasting 5-60 minutes, at least one unilateral symptom, at least one positive symptom, and aura accompanied by or followed by headache within 60 minutes 1
Critical Red Flags Requiring Urgent Evaluation
Do not dismiss atypical presentations as "just migraine" 7, 8:
- Prolonged aura >60 minutes (especially >72 hours): Requires urgent neuroimaging with MRI to exclude stroke, AVM, or structural lesions 7, 8
- Sudden, simultaneous onset of symptoms (suggests TIA rather than migraine) 1
- First-time aura: Difficult to distinguish from TIA if no gradual onset or if symptoms correspond to vascular territory 2
- Late onset of aura or dramatic increase in attack frequency warrants investigation 2
Special Considerations for Women of Childbearing Age
- Increased stroke risk: Migraine with aura significantly increases relative risk of ischemic stroke 2
- Contraception contraindication: Combined hormonal contraception with estrogens significantly increases stroke risk in women with migraine with aura and should be avoided 2
- Coexistence of migraine types: Many individuals with migraine with aura also experience attacks without aura; both diagnoses should be made when applicable 1