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Migraine with aura
By Mayo Clinic staffMayo Clinic Health Manager
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Definition
Some people who get migraines also experience a variety of mostly visual sensations that come before or accompany the pain of a migraine attack — a condition called migraine with aura.
Most often, a migraine with aura is characterized by visual disturbances such as flashes of light, zigzagging patterns or even blind spots. However, a migraine with aura may also be accompanied by other sensations, such as numbness or tingling in parts of your body and speech problems.
Pain relievers and prescription medications can treat a migraine with aura. But, preventive medications and self-care measures, including avoiding migraine triggers, may help you prevent a migraine with aura.
Symptoms
Visual disturbances are the most common feature of migraine aura. Signs and symptoms may include:
- Shimmering spots or stars
- Zigzag lines that gradually float across your field of vision
- Loss of vision
- Blind spots (scotomas)
- Flashes of light
These types of visual disturbances tend to start in the center of your visual field and move outward, or spread.
Other types of sensations may accompany your visual disturbances, including:
- Feelings of numbness, typically felt as tingling in an extremity or on your face
- Confusion
- Difficulty with speech or language
A migraine aura usually occurs within an hour before head pain begins and generally lasts from 10 to 30 minutes before disappearing. Rarely, aura may occur with no headache.
Along with the aura, other signs and symptoms of migraine with aura include:
- Severe head pain, often one-sided
- Sensitivity to light
- Nausea and vomiting
- Painful skin (cutaneous allodynia) — as many as two out of three people with migraine also experience painful skin sensations during normal activities, such as brushing hair, wearing contacts or wearing tight clothes
When to see a doctor
If you experience the signs and symptoms of migraine with aura, such as temporary vision loss or floating spots or zigzag lines in your field of vision, see your doctor immediately to rule out more serious conditions, such as stroke or retinal tear. Once these conditions have been ruled out, future migraines with aura don't need to be considered a potential sign of a more serious condition and won't require a visit to your doctor, unless your symptoms change.
Additionally, seek medical attention if you have a headache and:
- Seizures
- Confusion or a loss of consciousness
- You've experienced a blow to the head
- A stiff neck or fever
- Pain in the eye or ear
- You can't perform everyday tasks
Causes
The cause of a migraine with aura isn't clearly understood. However, it's believed that a visual aura is like an electrical or chemical wave that moves across the part of your brain that processes visual signals (visual cortex). As the wave spreads, it may cause these visual hallucinations.
A number of factors may trigger migraine, including:
- Stress
- Hormonal changes
- Sensory stimuli — such as bright lights or unusual smells
- Fatigue
- Changes in the environment
- Head trauma
- Hunger
- Certain medications
- Certain foods, especially those with preservatives
Risk factors
The following factors may increase your risk of migraine with or without aura:
- Family history. Migraines are more common in people with a family history of migraines.
- Sex. Women are three times as likely to have migraines as men are.
- Hormonal changes in women. Migraine may worsen or change during menstruation, pregnancy or menopause. Migraine may also worsen if you take birth control pills or hormone replacement therapy.
Complications
People who have migraine with aura are at a slightly higher risk of stroke. Women with migraines have an even higher risk of stroke if they smoke, take birth control pills or have high blood pressure.
Although the link between stroke and migraine isn't clearly understood, it could be connected to changes in the blood vessels or blood flow in your brain.
Preparing for your appointment
You're likely to start by first seeing your family doctor or a general practitioner. However, in some cases you may also be referred to a doctor who specializes in nervous system disorders (neurologist).
Because appointments can be brief, and there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. One of the most helpful things you can do is keep a headache journal. Each time you get a headache, write down a description of the pain — How severe is the pain? Where is it located? How long does it last? — as well as the time of day the headaches occurred and what you were doing when the headache began. Also, include what you were eating or drinking before the headache started, and if you're taking any medications or dietary supplements. A headache journal can offer valuable clues that may help your doctor diagnose your particular kind of headache and discover possible headache triggers.
- Write down key personal information, including any major stresses or recent life changes.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. List your questions from most important to least important in case time runs out. For migraine with aura, some basic questions to ask your doctor include:
- What type of headache am I experiencing?
- What kinds of tests, if any, do I need?
- Is my condition likely temporary or chronic?
- What types of treatments are available? Which do you recommend?
- What are the alternatives to the primary approach that you're suggesting?
- I have these other health conditions. How can I best manage them together?
- Are there any dietary restrictions that I need to follow?
- Is there a generic alternative to the medicine you're prescribing me?
- Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
- When did you first begin experiencing symptoms?
- How old were you when your symptoms first began?
- Where is the pain located?
- What types of visual symptoms or other sensations do you have?
- How long do they last?
- Are they always followed by a headache?
- How long do your headaches last?
- How often do you get headaches?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
What you can do in the meantime
Over-the-counter pain relievers may help reduce the pain of a migraine with aura. However, over-reliance on these products may cause a medication-overuse headache.
Tests and diagnosis
If you have typical migraines or a family history of migraine with aura, your doctor will likely diagnose the condition on the basis of your medical history and a physical exam.
But if your headaches are severe or sudden, your aura isn't followed by head pain, or the visual disturbances affect only one eye, your doctor may recommend certain tests to rule out more serious conditions, such as transient ischemic attack — a temporary decrease in blood supply to part of your brain — that could be causing your symptoms.
Your doctor may recommend:
- An eye (ophthalmologic) examination. During this exam, your doctor will use an instrument the size of a small flashlight (ophthalmoscope) to project a beam of light into your eye to examine the back of your eyeball (fundoscopy).
- Computerized tomography (CT). This X-ray technique produces detailed images of your internal organs, including your brain.
- Magnetic resonance imaging (MRI). This diagnostic imaging procedure produces images of your internal organs, including your brain.
Your doctor may also refer you to a doctor who specializes in nervous system disorders (neurologist) to rule out brain conditions that could be causing your symptoms.
Treatments and drugs
Several drugs are available to treat migraines. These range from over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) to prescription medications. Your doctor can help you decide which medications are best for your situation.
Medications that can be used to treat your migraine pain include:
- Analgesics. Over-the-counter pain relievers — such as acetaminophen (Tylenol, others), a combination of acetaminophen, aspirin and caffeine (Excedrin), ibuprofen (Advil, Motrin, others), and naproxen (Aleve, others) — may be all you need to relieve your headache pain. Prescription-strength analgesics also are available. Don't take analgesic drugs for more than 10 days in a month, because these medications can lead to what's known as a medication-overuse headache.
-
Triptans. When taken early in the course of a migraine, these drugs can quickly relieve migraine symptoms by acting on the nerves and blood vessels. This class of medications includes sumatriptan (Imitrex), zolmitriptan (Zomig), almotriptan (Axert), rizatriptan (Maxalt), naratriptan (Amerge), eletriptan (Relpax), frovatriptan (Frova), and a combination drug that includes sumatriptan plus naproxen (Treximet). Side effects of triptans include nausea, dizziness, drowsiness and, rarely, heart attack. People with a history of heart disease, stroke and high blood pressure and women who are pregnant should not take these medications.
Additionally, people who take the antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) should use these medications with caution, as there's a small risk of developing serotonin syndrome when these drugs are combined.
- Ergots. Ergotamine (Ergomar) is an older migraine treatment that tends to have more side effects than do triptan medications. It's also not recommended for people who have migraines with auras. Dihydroergotamine (D.H.E. 45, Migranal) works in a similar manner to ergotamine, but is more commonly prescribed because it's more effective and has fewer side effects.
- Anti-nausea drugs. Because nausea with or without vomiting is a common symptom of migraine, anti-nausea medications may be prescribed along with other migraine drugs. Drugs in this class include chlorpromazine, prochlorperazine and metoclopramide.
Preventive medications
Because overuse of analgesics can cause medication-overuse headaches, doctors recommend preventive drugs to reduce the frequency and severity of migraine attacks. Your doctor may recommend preventive medications if you're having more than four headaches a month, your headaches last more than 12 hours, or you're disabled by your migraines. Preventive medication options include:
- Cardiovascular medications. Certain classes of heart and blood pressure medications, including beta blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARB) may be prescribed to help prevent your migraines. Of these treatments, beta blockers, such as propranolol (Inderal LA) and timolol, are the most well-studied. It may take several weeks to months before these medications are effective, and they're not recommended for people with low blood pressure.
- Antidepressants. Tricyclic antidepressants, such as amitriptyline, can help prevent migraines. Side effects of these medications include drowsiness, dry mouth, constipation, heart palpitations and weight gain.
- Anti-seizure drugs. Certain anticonvulsants are effective in reducing the frequency of migraine, though the reason they work on migraine isn't clear. Divalproex sodium (Depakote), topiramate (Topamax) and gabapentin (Neurontin) — drugs normally used to treat the seizure disorder epilepsy — help prevent migraines. These medications can't be used by pregnant women, and they may cause weight gain.
Previously, some research had suggested that botulinum toxin type A (Botox) might be an effective treatment for migraine. However, more recent studies have failed to find a benefit, and botulinum toxin isn't recommended for migraine treatment.
Stress management
Cognitive behavioral therapy, a technique that teaches you more appropriate ways to deal with stressful situations, may help reduce the number of migraines you have.
Lifestyle and home remedies
Among the steps you can take to help limit or prevent migraine with aura are:
- Control stress
- Get enough sleep
- Avoid or manage migraine triggers
Common migraine triggers include:
- Stress or anxiety
- Certain foods, such as aged cheese, red wine, foods with monosodium glutamate (MSG) and meats preserved with nitrates
- Fatigue
- Certain medications, such as birth control pills or hormone replacement therapy
- Sensory stimuli, such as bright lights or strong odors
Alternative medicine
Nontraditional therapies may be helpful if you have chronic headache pain:
- Acupuncture. In this treatment, a practitioner inserts many thin, disposable needles into several areas of your skin. The penetration is so shallow and the needles are so thin that acupuncture generally causes little or no pain or discomfort. A number of clinical trials have found that acupuncture may be helpful for migraine pain, but evidence from these trials isn't strong enough for experts to routinely recommend this treatment.
- Biofeedback. Biofeedback appears to be effective in relieving migraine pain. This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses, such as muscle tension. This technique can be combined with preventive medications.
- Herbs, vitamins and minerals. There is some evidence that the herbs feverfew and butterbur may prevent migraines or reduce their severity. A high dose of riboflavin (vitamin B-2) also may prevent migraines by correcting tiny deficiencies in the brain cells. For others, coenzyme Q10 supplements may be helpful. Ask your doctor if these treatments are right for you. Don't use herbal supplements if you're pregnant.
- Cervical manipulation. There are no scientifically valid studies that prove that chiropractic or other spine-manipulation treatments are effective in the treatment of migraine. Of greater concern is that in rare cases, cervical manipulation has caused damage to the arteries that pass through the cervical spine to the brain. This damage has resulted in stroke and even death.
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