Migraine with Typical Aura
Migraine with typical aura (MTA) is the most common form of migraine with aura, which is one of the two major categories of migraine disorder. It is characterized by recurring attacks of temporary neurological symptoms, known as aura, that develop gradually and often – but not always – occur before or during a phase of headache pain. The other major category, migraine without aura, is for migraine with headache that is not accompanied by these aura symptoms.1
An estimated 5% of the population will experience migraine with aura at some point in their lives. Around 30% of people with migraine have aura symptoms during at least some of their migraine attacks, but less than 20% of people diagnosed with migraine with aura actually experience those aura symptoms with every single migraine episode. Women are also slightly more likely than men to experience migraine with aura.2
In the most recent update to the International Headache Society’s guidelines, The International Classification of Headache Disorders, 3rd Edition (ICHD-III), the category of migraine with aura was revised to include four different sub-types: migraine with typical aura, migraine with brainstem aura, hemiplegic migraine, and retinal migraine. The most frequent types of aura symptoms reported by patients are related to the visual, sensory, and speech/language systems. These types of symptoms are therefore classified as “typical aura” in the ICHD-III.
Symptoms of migraine with typical aura2
Visual aura are the most common kind of typical aura, experienced by more than 90% of patients. The first sign of visual aura is usually a small area of either brightness or blindness in the center of the field of vision, which typically spreads gradually outward from that central spot. This disturbance can take many different forms, such as moving zigzag lines, geometric shapes, blind spots, white or colored dots or stars, and flashes of brightness. The area of disturbance is often described as a crescent or C-shape with a shimmering outer edge, and vision tends to return to normal in the center as the disturbance spreads outward.
Reported by around 50% of patients, sensory aura are often described as a feeling of “pins and needles” or a burning sensation that starts in a particular spot (often the hand) and spreads slowly over that side of the body, face, and mouth. For many people, a feeling of numbness takes over the affected areas as the initial sensation subsides. Sensory aura often follow an experience of visual aura, but they can also occur as the only aura symptom in some cases.
Symptoms of speech and/or language aura can include trouble recalling words (most common), problems understanding language, and difficulties in reading and writing. About 30% of patients report having speech and/or language aura symptoms with migraines, making it the least frequently occurring kind of typical aura.
The ICHD-III states that typical aura symptoms usually last for more than five minutes but for less than an hour. However, a 2013 article reviewed the results of ten migraine studies that reported information about the duration of the participants’ typical aura symptoms. The authors reported that between 12%-37% of patients in those studies actually experienced typical aura that lasted for more than an hour.3 There are also rare cases in which typical aura have persisted for days or weeks.
Diagnosis of migraine with typical aura
According to the ICHD-III, a patient should be diagnosed with MTA if they have experienced two or more attacks that each involved at least one typical aura symptom that disappeared by the end of the migraine attack.
Each of those attacks is also required to fulfill at least two of the following conditions:
- At least one typical aura symptom spreads gradually over at least five minutes, and/or two or more symptoms occur one after the other.
- Each aura symptom lasts between 5-60 minutes.
- At least one aura symptom is limited to one side of the body.
- Aura is accompanied by headache, or headache follows within an hour.
Patients who experience brainstem aura (eg, vertigo, slurred speech, ringing in the ears, double vision, etc), motor aura (muscle weakness or paralysis on one side of the body), or retinal aura (temporary blindness in one eye) should be diagnosed with one of the other sub-types of migraine with aura.
Typical aura and headache
MTA can occur either with or without headache. Some people with MTA always have associated head pain, but others experience typical aura followed by minimal headache or even no headache at all. Still others have head pain during some MTA attacks, but not all. Whether headache occurs after or during the typical aura phase also differs among patients. One study indicates that many people (73%) experience headache during the aura phase, with about half of headaches occurring within 15 minutes of the aura symptoms.2
Due to variation in whether headache occurs at all, the ICHD-III classifies two different forms of MTA: typical aura with headache and typical aura without headache. As the name suggests, the first type of migraine is characterized by typical aura that either occur with headache or are followed by headache within an hour. The headache may or may not have classical migraine features, such as:
- Localized on one side of the head
- Pulsating quality
- Moderate to severe pain intensity
- Worsened by normal physical activity
- Sensitivity to light and/or sound
The second form of MTA, typical aura without headache, involves typical aura that are neither accompanied nor followed by headache. Without the telltale headache, this kind of MTA can be more difficult for clinicians to diagnose.
Causes and treatment
Researchers currently believe that migraine aura are caused in large part by what is know as cortical spreading depression. Evidence from neuroimaging studies indicates that before or during an aura symptom, there is decreased blood flow in and around the area of the brain that is related to that symptom. For example, visual aura would correspond to a reduction in blood flow to the part of the brain responsible for visual perception.2
The proper identification of migraine aura is crucial – particularly for MTA without headache – because the aura can resemble symptoms of much more serious conditions. Clinicians need to make sure that the symptoms are migraine-related and are not actually being caused by other major issues like stroke, a tear in the retina, or transient ischemic attack (TIA). TIA, a temporary blockage of blood flow in part of the brain, is known as a “mini-stroke.” It often occurs prior to severe stroke and can serve as a warning signal to seek treatment immediately. Diagnostic tools such as eye examination, CT scan, or MRI can be used to rule out other non-migraine conditions.
This is especially important for women with migraine (who are at a slightly higher risk of stroke), people who experience their first migraine aura after age 40, and in cases when aura are either very brief (less than five minutes) or very long-lasting (more than an hour).2,4
Understanding the specific set of aura symptoms that an individual patient experiences also plays an important role in determining the best treatment strategy.
Known potential triggers for MTA attacks are similar to other types of migraine with aura, such as stress, bright lights, physical exertion, disturbed sleep patterns, and certain foods and drinks. Patients are advised to keep track of symptoms in a headache diary that records descriptions, durations, when they occurred, and possible triggers.4
Recommended treatment options for MTA include4:
- Pain-relief medications taken at the first signs of migraine: OTC or prescription NSAIDs, triptans, ergotamines, dopamine blockers, and anti-nausea medications
- Preventive medications for people who experience very frequent migraines
- Stress management techniques
- Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 3rd edition. Cephalalgia. 2013;33:629-808.
- DeLange JM, Cutrer FM. Our evolving understanding of migraine with aura. Curr Pain Headache Rep. 2014 Oct;18(10):453.
- Viana M, Sprenger T, Andelova M, Goadsby PJ, et al. The typical duration of migraine aura: a systematic review. Cephalalgia. 2013 May;33(7):483-490.
- Mayo Clinic. Migraine with aura. June 4, 2014. Available at: http://www.mayoclinic.org/diseases-conditions/migraine-with-aura/basics/definition/con-20030404. Accessed November 2, 2014.