Migraine with aura: all the symptoms explained

Migraine with aura is migraine in which temporary neurological symptoms, most often visual ones such as zigzag lines, flashing lights or a blind spot, come before or at the start of the headache. About one in three people with migraine have aura. The symptoms build up gradually over several minutes and usually last between 5 and 60 minutes.

You might suddenly see flickering at the edge of your vision, a zigzag pattern that slowly grows, or a gap in what you see, as if someone has cut a piece out of the picture. Many people do not know exactly what an aura is, or that it can be much more than seeing strangely. Below we explain the symptoms, how to recognise them and when to get help.

What is a migraine aura?

An aura is a neurological event that happens just before or at the start of a migraine attack. It is caused by a slow wave of changed brain activity moving across the surface of the brain, a process called cortical spreading depression.

An aura is not a sign that something dangerous is happening in your head. It is a feature of migraine, an inherited brain condition in which the nervous system is temporarily oversensitive.

After the aura, most people get the headache phase, but not always: some people have an aura without any headache following it. This becomes more common as people get older.

What are the most common migraine aura symptoms?

Visual symptoms (the most common)

• Zigzag lines or flickering: bright, jagged lines that slowly spread. This is also called a fortification spectrum, because the pattern looks like the walls of a fort.
• Blind spots (scotomas): part of your vision disappears. You may see a blank space in the middle of someone's face, or be unable to read a word while the rest of the text is visible.
• Flashes of light: short, bright flashes, sometimes with changes in colour.
• Distorted vision: objects can look bigger, smaller or misshapen. People sometimes describe this as an "Alice in Wonderland" experience.

Changes in sensation

• Tingling: a pins and needles feeling that usually starts in the fingertips of one hand and slowly creeps up the arm to the face. Typical of migraine is that it moves gradually, unlike a stroke, where symptoms start suddenly.
• Numbness: the tingling area can go numb for a while. This is frightening but harmless, and it passes on its own.

Speech and language problems

Aphasia means difficulty finding words, forming sentences or understanding speech. You know exactly what you want to say, but the words will not come. This can be very frightening, but it is temporary. In a rare form called hemiplegic migraine, aura can also include temporary weakness on one side of the body.

Which aura symptoms are less well known?

• Confusion or disorientation: feeling unsure where you are or what you were doing.
• Changes in hearing: sounds seem louder or quieter than normal, or a ringing in the ears.
• Changes in smell: smelling things that are not there, such as burning or a sweet smell.

Not everyone has all of these symptoms. Your aura may look very different from someone else's, and even in the same person one aura can differ from the next.

Dizziness is not an aura symptom, but it can occur during a migraine attack. In vestibular migraine, dizziness is the main symptom, sometimes without any headache.

How serious is an aura migraine?

Aura symptoms can be frightening, but in themselves they are not dangerous. They are caused by temporary changes in brain activity, not by damage to the brain. Migraine with aura is linked to a small increase in the risk of stroke, mainly in people who smoke or take the combined contraceptive pill, so it is worth discussing these with your GP.

Is a migraine with aura a mini stroke?

No. A mini stroke (transient ischaemic attack, or TIA) and an aura can both cause visual problems, tingling or speech problems, but they behave differently:

• Aura builds up gradually: symptoms start small and spread over minutes. In a stroke or TIA, symptoms appear suddenly.
• Aura lasts 5 to 60 minutes: it has a clear beginning and end and passes on its own.
• Aura symptoms follow each other: first visual symptoms, then tingling, then perhaps speech problems. They rarely all start at once.
• Aura often adds something: flashing lights or tingling, where a stroke usually takes something away, such as vision or strength.
• A headache often follows: after the aura, most people get a migraine attack, though not always.

If you have aura symptoms for the first time, or you are not sure, contact your GP or call NHS 111 to rule out other causes.

What triggers migraines with aura?

The triggers are the same as for migraine without aura, and they differ from person to person. Common ones include changes in sleep, missed meals, stress or the period just after stress, hormonal changes, alcohol and bright or flickering light. A trigger is not a cause: the underlying cause is the migraine itself, and a trigger only makes an attack more likely on a given day.

When to get urgent help

Most headaches are not dangerous, but some symptoms need urgent attention. Call 999 or go to A&E if you have:

• a sudden, very severe headache that reaches its worst within seconds or minutes
• weakness or numbness on one side of the body or face
• slurred speech or difficulty understanding speech
• loss of vision that does not return
• a first ever aura after the age of 50
• a headache with a fever and a stiff neck

If you are worried but it does not feel like an emergency, call NHS 111.

What can you do during an aura?

Once an aura has started, you cannot stop it. But you can take action:

• During the aura: find a quiet place, dim the lights and wait until it passes. If you are driving, stop safely, as your vision may be disturbed for a while. Do not drive until the symptoms have gone.
• Acute medication: triptans tend to work best when taken at the start of the headache rather than during the aura itself. Your migraine specialist will advise you on the right timing for you.
• Preventive treatment: if you have frequent attacks, preventive treatment can reduce how often they happen. Effective options developed specifically for migraine include the gepants atogepant and rimegepant, and the monoclonal CGRP inhibitors erenumab, fremanezumab and galcanezumab.

You do not have to live with this

Migraine with aura can be frightening and limiting, but good treatment is available. Many people wait years for the migraine care they need, and that does not have to be the case for you.

Wondering whether your symptoms fit migraine? Take our migraine test, read more about what migraine is and our treatment, or see how to start.

This article was written by the medical team of The Migraine Clinic.