Migraine With Aura
Aura consists of temporary, fully reversible neurological symptoms that most often occur before the headache, but may also appear during the headache or even occur without any subsequent headache.
The best-known form is visual aura: shimmering lights, zigzag lines, bright geometric shapes or a gradually changing area of the visual field. Aura can also cause sensory symptoms, speech or language disturbances and, more rarely, other neurological phenomena.
How migraine aura usually develops
Aura is associated with a transient change in the activity of specific areas of the cerebral cortex. Symptoms usually develop gradually rather than appearing at full intensity immediately.
Aura is not always visual
Visual aura
The most common type. Symptoms may include shimmering spots, zigzags, bright lines, geometric patterns, a scintillating scotoma or a gradually enlarging area of visual loss.
Sensory aura
This often presents as tingling that gradually spreads through the hand, arm, face or tongue. Numbness may follow the positive sensory symptoms.
Speech or language aura
A patient may have difficulty finding words, understanding language or producing speech. Such symptoms need to be carefully distinguished from an acute vascular event.
What visual aura can look like
Visual symptoms are the most common manifestation of migraine aura. The phenomenon often begins in a small area of the visual field and then expands or moves over several minutes.
Patients may describe bright lines, zigzags, flashing or shimmering lights, geometric patterns, visual “ripples”, a blind spot, or a combination of positive and negative visual phenomena.
The gradual evolution of the visual disturbance is often more diagnostically useful than the exact shape of the visual phenomenon.
Positive and negative symptoms
Positive visual symptoms are things that appear in the visual field: flashing lights, shimmering, zigzags or bright lines.
Negative symptoms represent temporary loss of part of vision: a scotoma, a missing area or darkening of the visual field.
Both types may occur together during a typical migraine aura.
Typical visual aura usually does not originate in the eye
The term “ocular migraine” is often used very broadly and may be misleading. In a typical visual migraine aura, the symptom originates in the visual cortex of the brain, not in the retina itself.
Typical visual aura
The visual phenomenon affects a part of the visual field and usually involves information coming from both eyes, although a patient may feel that the disturbance was present in only one eye.
True visual loss in one eye
Sudden or first-time loss of vision that is genuinely limited to one eye should not automatically be labelled migraine aura. Ophthalmological and vascular causes need to be considered.
What is considered when diagnosing migraine with aura
According to ICHD-3, migraine with aura involves recurrent attacks of fully reversible focal neurological symptoms.
Typical aura is characterised by a combination of the following features:
- at least one aura symptom spreads gradually over 5 minutes or longer;
- when several symptoms occur, they may develop in succession;
- each individual symptom usually lasts 5–60 minutes;
- at least one aura symptom may be unilateral;
- at least one symptom is positive, such as flashing lights or tingling;
- headache accompanies the aura or follows within 60 minutes.
Why the sequence of symptoms matters
The symptom begins gradually
For example, a small area of shimmering vision may appear near the centre of the visual field.
The pattern changes over several minutes
A shimmering area or scotoma may enlarge, while sensory tingling may spread from the hand to the forearm and face.
The symptom resolves completely
Migraine headache may then begin, but in some attacks no headache occurs at all.
Migraine aura can resemble a transient vascular event
Transient visual, sensory or language symptoms can occur both in migraine aura and in transient ischaemic attack. The diagnosis therefore cannot be made from one isolated feature.
| More typical of migraine aura | More concerning features |
|---|---|
| The symptom develops gradually over several minutes. | The symptom begins suddenly and is immediately maximal. |
| Positive phenomena may occur: flashing lights, zigzags or tingling. | Sudden loss of function: loss of vision, sensation, strength or speech. |
| Different symptoms may develop one after another. | Several neurological deficits begin simultaneously and suddenly. |
| Similar stereotyped episodes have occurred before. | The episode is new, particularly at an older age or in a person with vascular risk factors. |
Can aura occur if no headache follows?
Yes. ICHD-3 recognises typical aura without headache as a distinct presentation.
A person develops fully reversible visual, sensory or speech/language symptoms typical of aura, but no migraine headache follows.
Why diagnosis is especially important
Without headache, the episode may more closely resemble TIA, a focal epileptic seizure or another neurological disorder.
Particular care is needed when such an episode occurs for the first time or begins later in life.
There are rarer forms of migraine with aura
Hemiplegic migraine
The aura includes motor weakness. This is a separate subtype of migraine and requires particularly careful differential diagnosis.
Migraine with brainstem aura
Symptoms may include a combination of dysarthria, vertigo, tinnitus, diplopia or ataxia.
Retinal migraine
A rare form with fully reversible monocular visual symptoms. Other causes of temporary vision loss in one eye must be excluded before this diagnosis is made.
Does migraine with aura always require MRI?
No. If a person has a long history of stereotyped typical aura, the neurological examination is normal and there are no concerning features, MRI does not need to be repeated for every episode.
The diagnosis of typical migraine aura is primarily clinical.
The threshold for investigation is lower when
- aura occurs for the first time;
- the usual aura pattern changes substantially;
- a symptom is unusually prolonged or persistent;
- motor weakness occurs;
- aura begins for the first time later in life;
- unusual brainstem symptoms occur;
- aura occurs without headache and the presentation is atypical;
- there are other features suggesting a secondary disorder.
Does migraine with aura mean a high risk of stroke?
Population studies show an association between migraine with aura and a modestly increased risk of ischaemic stroke. This is a statistical association and does not mean that a typical migraine aura is itself a stroke or will necessarily lead to one.
For an individual patient, age, smoking, blood pressure, other medical conditions and additional vascular risk factors also matter.
What helps establish the correct diagnosis
Exact description of the symptom
What exactly was seen or felt: flashing lights, a scotoma, tingling, numbness, speech disturbance or another symptom.
Timing and sequence
Whether the symptom started suddenly or developed gradually, how long it lasted and whether another symptom followed.
Relationship to headache
When the headache began: before the aura, during it, after it or not at all.
Treatment depends on more than the presence of aura
For many patients, treatment of migraine with typical aura follows the same general principles as treatment of migraine without aura: effective acute therapy, control of attack frequency and timely preventive treatment when needed.
Diagnosis of migraine with aura with Dr Lidiia Prakhova
Dr Lidiia Prakhova is a specialist neurologist with more than 35 years of clinical experience. Migraine and other headache disorders are among the areas of her outpatient neurological practice.
When aura is present, it is especially important to reconstruct the type, sequence and duration of neurological symptoms, assess whether they fit a typical migraine aura and determine whether additional investigations are needed.
Frequently asked questions about migraine with aura
How long does aura usually last?
Can aura occur without headache?
Can an arm or the face become numb during aura?
Can aura affect speech?
Does visual aura always affect only one eye?
Is MRI required after a first aura?
Is aura a mini-stroke?
Can hormonal contraception be used with migraine with aura?
Main medical sources
- Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (ICHD-3). Cephalalgia. 2018;38(1):1–211. doi:10.1177/0333102417738202.
- International Headache Society. 1.2 Migraine with aura. ICHD-3.
- International Headache Society. 1.2.1 Migraine with typical aura. ICHD-3.
- Evans RW, Burch RC, Frishberg BM, et al. Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence-Based Guideline. Headache. 2020;60(2):318–336. doi:10.1111/head.13720.
- Lebedeva ER, Olesen J. Transient focal neurological symptoms and headache: is it TIA or migraine with aura? J Headache Pain. 2025;26:87. doi:10.1186/s10194-025-02038-8.
- Sacco S, Merki-Feld GS, Ægidius KL, et al. Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation and the European Society of Contraception and Reproductive Health. J Headache Pain. 2017;18:108. doi:10.1186/s10194-017-0815-1.
With aura, an accurate description of how the symptoms developed is especially important
Gradual development, sequence, duration and complete reversibility help identify a typical migraine aura. If an episode occurs for the first time, has changed from previous attacks, is unusual or raises diagnostic uncertainty, the need for additional investigation should be assessed.
