Migraine with Visual Aura

Migraine with visual aura is recurrent headache attacks preceded or accompanied by fully reversible binocular visual symptoms that develop gradually over at least 5 minutes and last 5 to 60 minutes. Visual aura is the commonest type and occurs in about a quarter to a third of people with migraine.

• Underlying process is cortical spreading depression with trigeminovascular activation.
• Strong family history, female predominance after puberty.
• Aura raises ischaemic stroke risk, especially in women who smoke or take oestrogen containing contraceptives.

Expanding zigzag fortification spectrum with a shimmering arc or scotoma that drifts across the visual field over minutes, followed within 60 minutes by unilateral throbbing headache, nausea, photophobia and phonophobia, lasting 4 to 72 hours.

• Aura may occur without headache.
• Prodrome (yawning, mood change, food craving) hours before; postdrome of fatigue.
• Differential diagnosis: occipital seizure, transient ischaemic attack, retinal detachment, retinal migraine, vertebrobasilar insufficiency, arteriovenous malformation, giant cell arteritis, cluster headache, cerebral venous thrombosis.
• Complications: migrainous infarction, persistent aura without infarction, status migrainosus, medication overuse headache, chronic migraine, aura triggered seizure.

Clinical, on history; at least two attacks with reversible spreading visual symptoms.

• Neurological examination, blood pressure, fundoscopy.
• Neuroimaging (MRI) if aura is atypical, motor weakness, aura over 60 minutes, first attack after age 40, or abnormal examination.
• Blood glucose, full blood count, ESR where indicated; HIV serology in adults with new headache pattern.

Treat attacks early, prevent frequent attacks, and manage vascular risk.

• Supportive: dark quiet room, hydration, regular sleep and meals, trigger diary, exercise, caffeine moderation.
• Pharmacological, acute: aspirin 900 mg, ibuprofen 400 to 600 mg or naproxen 500 mg orally, with metoclopramide 10 mg; sumatriptan 50 to 100 mg orally at onset of headache (not during aura), may repeat after 2 hours, maximum 300 mg in 24 hours. Prevention (4 or more attacks monthly or disabling): propranolol 80 to 160 mg daily in divided doses, or amitriptyline 10 mg at night increasing to 50 mg, or topiramate 25 mg at night increasing weekly to 50 mg twice daily, or candesartan 8 to 16 mg daily.
• Procedures: none routinely; greater occipital nerve block for refractory attacks.
• Special groups: avoid combined oral contraceptives and use progestogen only or non hormonal methods; pregnancy, paracetamol 1 g and metoclopramide for attacks, low dose aspirin permitted, avoid valproate and topiramate; children, paracetamol 15 mg/kg or ibuprofen 10 mg/kg.
• Red flags: aura over 60 minutes, motor weakness, speech or brainstem aura, thunderclap onset, fever, papilloedema, new onset after 40 years, change in pattern.
• Follow-up: review at 6 to 8 weeks for effect, then every 3 to 6 months; limit acute analgesics to under 10 days per month; assess cardiovascular risk and stop smoking.