Hello everyone, welcome to Heads Up, the weekly podcast of the National Headache Foundation. I’m Dr. Lindsey Whitesell, migraine strategist, founder of the Facebook group Migraine Nation, and chronic daily migraine survivor. I am here with Dr. Vincent Martin. He is the head of the worry and Facial agony inside at the University of Cincinnati, and he is also the leader of the civil agony base.

Topic Introduction: Migraine with Aura

Hello, Dr. Martin, how are you doing today? Good, Lindsey, are there great? All right, our topic today is Aura, migraine with aura. 20% of those of us with migraine experience migraine with aura. We want to talk about what aura is, why do we get them, when should we be worried if there is an aura symptom that’s worrisome.

Types of Migraine Aura

Migraine Auras are usually visual, but they can also be sensory or motor or verbal, so we’re running to talk about all those types of aura. So, the early question I have is, What details an aura? What is it that we think causes or exactly or leads to an aura?

What Causes Aura

Well, an aura occurs because of a wave of electricity that goes along the surface of the brain, and that’s called, what we think it’s called, a cortical spreading depression, although we’re not 100% sure that happens in humans. But this wave, when it involves the visual cortex or the part of the cortex that involves the vision, you’ll get a visual aura; when it involves the sensory cortex, that’s the part of the brain that’s involved in feeling, then you get a sensory aura; and when it involves the motor cortex, which is necessary for motor function or strength of your arm or leg, then you get another kind of aura called a motor aura.

Headache and Postdrome Phases

So, consequently, after the aura phase is the headache phase, which is where you get the head pain and the nausea and the vomiting and so forth. And then finally, there’s something called the postdrome, which is kind of a recovery phase where you can be very fatigued; sometimes you can urinate a lot during that period as well. So, there’s really five different phases of a migraine attack.

Timing of Aura in Relation to Headache Phase

Okay, and do or does aura always precede the headache phase, or can it sometimes come during the headache phase? Well, classically, they say that the aura occurs before, and I would say that’s probably the most common pattern. But there can be some people who will develop aura right when the headache phase begins; some may even develop it midway into the headache phase.

Aura Without Head Pain

So, it’s commonly thought that it occurs before, but it can occur during other phases as well. Is it possible to experience aura without head pain? Experience aura without head pain? Yes, that occurs more commonly in patients as they age.

Late-life Aura Occurrence

In fact, there can be some elderly or older patients who start developing, say, a visual aura in later life, and they may not have any headache at all, and they may not have had any past history of migraine whatsoever. So, and that’s called late-life accompaniments, which is kind of a funny way to describe that. But that can occur in headache patients as well.

Different Aura and Headache Combinations

You can have a person that has migraine attacks that don’t have any aura, and then you can have some that just have an aura but no headache, and you can have some that have an aura plus a headache. So, there can be all sorts of different combinations of aura in patients.

Optical  Aura Description

Okay, so let’s start by conversing about optical auras. Optical  aura, I believe, is the most common, and that’s what people most regularly think of when they think of aura.

Personal Description of Visual Aura

So, how are visual auras usually described? Well, actually, I get one myself, so what happens is I’ll start off seeing this like real small little speck in my vision, and it would kind of flash and so forth, and then it gradually gets bigger, and it gets bigger to the point it becomes kind of crescent-shaped and is playing in my outside part of my vision, and it’s worst extent when I hold my finger up, I can’t even see my finger mate.

Duration of Aura

So, an aura has to last a characteristic duration; classically, it lasts anywhere from five to sixty minutes, but there can, you know, there can be situations where the aura lasts much longer than that. There could be some instances where it may last hours or even days, and even rarely could last for weeks.

Personal Common Visual Aura Experience

Right, I think that my most common one that I always think of I’ve had it since I was a very young child, and I always just thought it was normal, and I always described it as it looks like jellyfish with no legs; it’s just these little things in my vision, and it’s been the same one since I was very young.

What Is a Scotoma?

Scotoma? I do get some different ones, but that’s my most common one. So, what is a scotoma? A scotoma is a blind spot in the vision, and that I see that too, but I see the little blind spot, and then around it is like this geometric shape, and then that gradually gets larger to where it becomes that crescent-shaped image that I described before, but that’s a scotoma, and that’s another form of visual aura impact.

Sensory Aura Description

All right, so let’s move to sensory aura. What is a sensory aura, and what do people most commonly describe those as feeling like?

Sensory Aura Characteristics

Well, a sensory aura can either be tingling or numbness of one part of the body; it might start on the face and then march down to the arm and then march finally down to the hand, and that’s the one thing that distinguishes an aura from, say, a TIA or stroke.

Difference Between Aura and Stroke Symptoms

TIA is transient ischemic attack; that’s where there’s low blood flow to the brain. The symptoms of an aura tend to march, so whether it’s a visual aura where it starts off small and then gradually gets bigger, or whether this sensation of a sensory aura starts in one location and moves to another, where there’s a stroke, you would have all the symptoms exactly the same time.

Sensory Aura Patient Descriptions

Okay, so that’s an important distinguishing feature, but that’s the way that many patients describe a sensory aura.

Dysphasic Aura Explained

Okay, what is a dysphasic aura? Well, that’s dysphasic simply where patients start to slur their speech, right? Might be talking, and they might start probably going like this, and you may—it may be completely unrecognizable, and that would be considered a speech aura.

Speech Aura Podcast Reference

Okay, and we do have an entire podcast episode on speech problems related to migraine if you look back at our previous episodes, so we go into that in depth.

Aura Duration Recap

And now, you already answered this question, but let’s bring it up one more time: how long do auras usually last? Well, they have a characteristic duration when they occur, typically, and I said before they can last longer than that, but it usually are five to sixty minutes is the classic duration of an aura.

Multiple Aura Types in One Attack

Okay, and do multiple types—some people experience multiple types of aura at once? Yes, some people will have a visual aura, and then they might have, along with that, they may have a sensory aura, and then some people may even have the whole tamale; they’ll get the motor aura, and they’ll get the sensory aura, and the visual aura in the same attack, so that you can have different types of aura that occur with the same migraine. Yes.

Motor Aura in Hemiplegic Migraine

Well, the aura that occurs with hemiplegic migraine is a motor loss, so patients will get either paralysis or the weakness of, say, their face, their arm, or their leg, and that can be very distressing because the first time that happens you don’t think of it as a migraine; you’re probably thinking that you’re having a stroke.

Distinguishing Features of Hemiplegic Migraine

But once again, one of the main distinguishing features is the fact that the symptoms kind of march; they start off at one location and then go to another. But I would say that if you have a motor aura, or what we call hemiplegic migraine, that at least with the first episode, until you’ve been diagnosed, you probably should seek immediate medical attention because really it can be difficult to differentiate from a stroke.

When to Seek Emergency Care

Right? So, other than these auras that occur with hemiplegic migraine, where you probably should seek medical attention, let’s really quick go back over the auras that we have discussed. Are there any symptoms where you would say go to the ER? Because I do know that people, when they get a new aura symptom, they sometimes become afraid, so at what point do you think they should seek medical attention?

Visual Aura and Emergency Room Visits

Well, if they have something that sounds like what we described as a visual aura, then I would not recommend people going to the emergency room for a visual aura. That would be—you’d be sending countless people. Visual auras are very, very common.

Sensory, Motor, and Speech Aura ER Recommendations

The sensory aura and the motor aura are a little bit different, and even the speech aura, because when it happens for the very first time, you don’t really have any history; it’s never happened before; you don’t know what you’re dealing with. So, those, in those instances, you might want to consider going to the ER if it’s the first time.

Diagnosis and ER Visits for Aura

Once you’ve been diagnosed with hemiplegic migraine, it’s happened 15 or 20 times, or once you’ve been diagnosed with the sensory aura and you know what it is, you know it’s not a stroke or TIA, and then you don’t run to the ER each and every time with those symptoms.

Additional Notes on Aura Sensitivity

Okay, all right, is there anything else you’d like to add to our conversation on aura?

Well, I think there’s a number of interesting things about aura. Number one is that patients with aura seem to be more sensitive to trigger factors, so there’s something about patients that have aura which make them a little bit different than those that do not have auras.

Aura and Menstrual Migraine

Auras can occur in women around the menstrual period, although they’re probably less common, so the headaches that are called menstrual migraines in women that occur two days before and two days after, in most instances, are going to be migraine without aura, although occasionally they can be migraine with aura, and there can be a slight increased risk of other medical illnesses with aura as well.