Visual Aura

Visual aura is a temporary visual disturbance that typically precedes or accompanies a migraine headache. It usually includes positive visual phenomena—seeing things that aren't there, like zigzag lines, shimmering spots, or flashing lights—and often includes an expanding area of visual loss.

What Visual Aura Looks Like

Classic migraine visual aura features:

Positive phenomena (seeing something):

• Scintillating scotoma—flickering, shimmering arc
• Fortification spectra—zigzag lines like castle walls
• Photopsia—flashing lights
• Kaleidoscope effects
• Sparkling or glittering dots
• Heat wave or shimmer effect

Negative phenomena (losing vision):

• Scotoma—blind spot that may expand (different from vision loss from optic nerve disease)
• Hemianopia—loss of half the visual field (similar to stroke but temporary)

Characteristic features:

• Starts small and expands outward over minutes
• Affects both eyes (homonymous—same side in each eye)
• Lasts 20-60 minutes typically
• May be followed by headache, nausea, light sensitivity (photophobia)
• Can occur without headache ("acephalgic migraine")

Timeline of Typical Migraine Aura

1. Onset: Small visual disturbance begins, often near center of vision
2. Spread: Expands gradually over 5-20 minutes
3. Duration: Total aura lasts 20-60 minutes
4. Resolution: Visual symptoms fade
5. Headache phase: May follow within 60 minutes (or may not occur)

Migraine Aura vs. Other Visual Phenomena

Feature	Migraine Aura	TIA/Stroke	Retinal Problem
Onset	Gradual (5+ min)	Sudden	Sudden
Duration	20-60 min	Minutes to hours	Variable
Affects	Both eyes (homonymous)	Depends on location	One eye
Positive phenomena	Yes (zigzags, sparkles)	Rare	May have flashes
Expansion	Characteristic spreading	No	No
Followed by headache	Often	Unusual	No

When Visual Phenomena Are NOT Migraine

Other Causes of Visual Phenomena

Eye Causes

Posterior vitreous detachment

• Flashes in peripheral vision
• New floaters
• One eye
• Usually older adults

Retinal tear/detachment

• Flashes of light
• Curtain or shadow over vision
• One eye
• Emergency

Neurological Causes

TIA (transient ischemic attack)

• Sudden onset
• May have other neurological symptoms
• Stroke risk factors present

Occipital seizure

• Brief (seconds to minutes)
• Stereotyped (same each time)
• May have other seizure features

Other

Visual snow syndrome

• Persistent "static" in vision
• Different from migraine aura
• See visual snow syndrome

Entoptic phenomena

• Normal visual phenomena (floaters, blue field entoptic)
• Not pathological

When to Seek Care

How Visual Aura Is Diagnosed

Diagnosis is usually clinical (based on description):

Detailed History

• Exact description of what you see
• How long it lasts
• Whether it spreads or expands
• Timing relative to headache
• Frequency of episodes
• Any associated symptoms

Examination

• Complete eye exam (usually normal)
• Neurological exam (usually normal)
• Visual field testing if indicated

Testing (if atypical features)

• MRI brain—to rule out structural causes
• Visual field testing—to document any field loss
• OCT—if optic nerve involvement suspected
• EEG—if seizures suspected
• Cardiac evaluation—if stroke risk factors present

Treatment of Migraine with Aura

During Aura

• Find a quiet, dark place if possible
• Avoid driving until aura resolves
• Take acute migraine medication if appropriate
• Some people find caffeine helpful

Prevention (if frequent)

• Migraine preventive medications—various options
• Lifestyle modifications—regular sleep, meals, exercise
• Trigger identification and avoidance
• Magnesium supplementation—may help some people

Special Considerations

• Estrogen-containing contraceptives—generally avoided in migraine with aura due to stroke risk
• Triptans—generally safe to use, but not during aura phase
• Cardiovascular risk—slightly increased in migraine with aura; manage risk factors

Frequently Asked Questions

Is migraine aura dangerous?

Typical migraine aura itself isn't dangerous, though it can be disabling temporarily. However, migraine with aura is associated with slightly increased cardiovascular risk over time, making risk factor management important.

Can I drive during an aura?

No. Visual aura significantly impairs vision. Pull over safely if an aura starts while driving, and wait until it completely resolves before continuing.

Why do I get aura without headache?

This is called "acephalgic migraine" or "silent migraine." The aura is the same phenomenon; the headache phase simply doesn't follow. This is common and generally follows the same patterns as migraine with headache.

Should I go to the ER for migraine aura?

Not usually, if you have a history of similar auras. However, seek emergency care for your first ever aura, aura with unusual features, aura lasting more than 60 minutes, or any neurological symptoms like weakness or speech difficulty.

Can aura happen in both eyes?

Yes—in fact, this is typical. Migraine aura usually affects the same half of the visual field in both eyes (homonymous). This is because the disturbance is in the brain, not the eyes. If you cover one eye and the aura goes away, it may not be typical migraine.

Do children get visual aura?

Yes, children can have migraine with visual aura, though their descriptions may be different. Alice in Wonderland syndrome (distorted body image, size perception) is a migraine variant more common in children.

References