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What is migraine aura?
What is migraine aura?
Migraine aura is a set of reversible neurological symptoms caused by a wave of temporary changes in brain activity called cortical spreading depression.
Typical aura features:
Gradual onset: Symptoms develop over 5 or more minutes.
Duration: Most symptoms last between 5 and 60 minutes.
Evolution: Symptoms may "march" (e.g., vision changes followed by tingling).
Resolution: Symptoms resolve completely once the aura finishes.
Aura can occur before or during a headache, and aura can occur with or without headache. As people age, it is common to experience the aura without any headache at all (sometimes called "silent migraine").
What does migraine aura feel like?
What does migraine aura feel like?
Visual symptoms
Visual symptoms
People may see zig-zag or shimmering lines, flickering lights, blind spots that slowly expand, or distorted or wavy vision.
These visual changes often start small and spread across the visual field over time.
Sensory symptoms
Sensory symptoms
Some people experience tingling, pins-and-needles, or numbness that slowly moves up an arm or across the face.
Speech symptoms
Speech symptoms
Less commonly some people experience difficulty finding words, and slowed or effortful speech.
These symptoms are temporary and resolve fully.
Rarely, a person may experience true weakness with migraine aura. If you experience sudden actual weakness or the inability to move a limb, this requires urgent medical assessment to rule out a stroke. Call 911.
Distinguishing migraine aura from stroke and TIA
Distinguishing migraine aura from stroke and TIA
Distinguishing migraine aura from stroke or transient ischemic attack (TIA) is important. There can be overlap between migraine aura and stroke, however some signs and symptoms are more suggestive of either migraine aura or stroke.
Migraine aura is a diagnosis that should be given by a medical doctor and medical attention should be sought when experiencing possible aura (especially the first time). If there is a concern that you or someone else is experiencing a new possible stroke, then 911 should be called for urgent evaluation.
More suggestive of
aura
More suggestive of
aura
Gradual onset (≥5 minutes)
Positive symptoms (blind spots or scotomas, colours, zig-zag lines, tingling or pins and needles)
Aura symptoms spread subsequentially (e.g., fist visual, then sensory, etc.)
Fully reversible
Duration 5–60 minutes
Often followed by headache (but not necessary)
More suggestive of
stroke
More suggestive of
stroke
Sudden onset of all symptoms
Negative symptoms (vision loss, sensation loss, weakness)
No march or progression (i.e., symptoms start simultaneously)
Persistent symptoms beyond 1 hour
Severe weakness
Severe speech or language impairment
When to seek urgent medical care (call 911)
When to seek urgent medical care (call 911)
Migraine aura and stroke can both mimic each other. Missing stroke can be devastating. Seek urgent medical attention if:
This is your first-ever aura.
Symptoms are sudden, simultaneous, and severe.
Symptoms last longer than 60 minutes.
You experience true weakness, confusion, or severe trouble speaking.
The pattern of what you are experiencing is dramatically different from your usual auras.
Birth control and migraine aura
Birth control and migraine aura
Safest
birth control
Safest
birth control
These options have no known association with increased stroke risk.
Progesterone-only pill
Subdermal implant
Depot injection
Hormonal IUD (e.g., Mirena)
Non-hormonal copper IUD
Medium risk
birth control
Medium risk
birth control
These contain less than 35 micrograms of ethinyl estradiol.
Low-dose combined pills
Combined contraceptive patch
Vaginal ring
Highest risk
birth control
Highest risk
birth control
Contraceptives containing more than 35 micrograms of estrogen are generally avoided for patients with migraine with aura due to a higher risk of stroke.
Combined hormonal contraceptives (pill, patch, ring) that contain estrogen are generally not recommended for people with migraine aura.
Why?
Estrogen increases blood clot risk
Migraine with aura may independently increase stroke risk
Together, the risk may become significantly higher for some people
Importantly, the quality of the evidence supporting these recommendations is low, and they are made out of abundance of caution. You can explore the position statement from the European Headache Federation and the European Society of Contraception and Reproductive Health here.
At the Ottawa Headache Centre, we can help you understand of what your true risk is so that you can make an informed decision that fits your lifestyle and makes sense with your other health needs.
If you are unsure about how to navigate birth control options, ask your doctor for a referral.
What if migraine aura becomes more frequent after starting estrogen-containing contraception?
What if migraine aura becomes more frequent after starting estrogen-containing contraception?
If migraine aura becomes more frequent, more intense, lasts longer, or changes in character after starting an estrogen-containing contraceptive (such as a combined pill, patch, or ring), the estrogen should be stopped and you should contact your doctor.
An increase or change in aura after starting estrogen may signal that the medication is not a safe option for you, even if it was initially felt to be reasonable.
In this situation:
Stop the estrogen-containing contraceptive
Use an alternative form of contraception in the meantime
Seek medical review to reassess migraine symptoms and contraceptive options
This recommendation is precautionary. While the absolute risk of serious complications remains low, a change in aura pattern suggests a shift in neurological risk, and continuing estrogen is not advised until you are reassessed medically.
After reassessment, most people can safely transition to:
A progestin-only contraceptive, or
A non-hormonal option
If you notice new neurological symptoms that are sudden, severe, or do not resolve, seek urgent medical care.
Managing migraine aura at the Ottawa Headache Centre
Managing migraine aura at the Ottawa Headache Centre
General treatment of migraine aura
General treatment of migraine aura
There is no specific medication that stops aura once it has started. Treatment focuses on:
Treating the headache and associated migraine symptoms that follows with acute medications
Preventing future migraine attacks
Preventive migraine treatments can reduce how often aura occurs.
The same preventive medications that are used for migraine without aura, can be used for migraine with aura including non-specific oral preventives, CGRP antagonists, and onabotulinumtoxinA (Botox ®).
Expert considerations in treating migraine aura
Expert considerations in treating migraine aura
Occasionally, other preventives including anti-seizure medications (e.g., lamotrigine) are used on a selective basis. For some people migraine aura is a due to a secondary cause of headache and may respond to antiplatelet medications (e.g., aspirin) or anticoagulants.
Next steps
Next steps
Whether you are seeking a first-time diagnosis or advanced relief, our specialized pathways are designed to get you the right care, faster.
New to the clinic?
New to the clinic?
Learn how to get referred and how to prepare for your first specialist consultation to ensure an accurate diagnosis.
Explore advanced prevention
Explore advanced prevention
If your auras are frequent or disabling, lifestyle changes alone may not be enough. Explore our specialized medical programs:
Common questions about migraine aura
Common questions about migraine aura
What are examples of the visual symptoms of migraine aura like?
What are examples of the visual symptoms of migraine aura like?
Migraine aura can present with many different types of visual disturbances. In general, the most common disturbances include:
A blind spot that may move or enlarge
Flashing lights
Colours that appear in the visual field
Jagged lines or zig-zag lines
Distortions to the objects
For examples of visual aura take a look at the visual aura table below from the International Headache Society.
When should I seek medical attention for possible migraine aura?
When should I seek medical attention for possible migraine aura?
Seek medical attention if:
This is your first-ever aura
Aura symptoms are sudden, simultaneous, and severe
Aura symptoms are lasting hours
There is weakness, confusion, or trouble speaking
The symptoms are very different from prior auras
You suddenly have a very high frequency of aura out of keeping with your typical pattern
When in doubt, it is appropriate to seek urgent care.
How is migraine aura treated?
How is migraine aura treated?
There is no specific medication that stops aura once it has started. Treatment focuses on:
Treating the headache and associated migraine symptoms that follows
Preventing future migraine attacks
Preventive migraine treatments can reduce how often aura occurs.
The same preventive medications that are used for migraine without aura, can be used for migraine with aura including non-specific oral preventives, CGRP antagonists, and onabotulinumtoxinA (Botox ®). Occasionally, other preventives including anti-seizure medications (e.g., lamotrigine) are used on a selective basis.
Does migraine aura increase the risk of stroke?
Does migraine aura increase the risk of stroke?
Migraine with aura may be associated with a small increase in stroke risk, particularly in younger women.
To put this into perspective:
Baseline stroke risk in young women is very low
Migraine with aura approximately doubles the relative risk
Because the baseline risk is low, the absolute risk remains low
Other factors have a much larger impact on overall risk such as:
Smoking
Using estrogen-containing hormonal contraception
Additional vascular risk factors (e.g., high blood pressure, high cholesterol, diabetes, etc.)
For most people, the absolute risk remains very low. We can help assess individual risk and guide safe treatment choices.
If I have migraine with aura, does this mean I can never use estrogen-containing contraception?
If I have migraine with aura, does this mean I can never use estrogen-containing contraception?
No — not necessarily.
Migraine with aura is associated with a small increase in stroke risk, and estrogen-containing contraception can also increase that risk. For this reason, estrogen-containing contraceptives are usually avoided in people with migraine aura especially when there are alternative forms of contraception.
However, this is not an absolute rule, and decisions should be individualized.
In some situations, estrogen-containing contraception may still be considered, particularly when:
There are important medical or gynecologic reasons for using estrogen (e.g., severe abnormal uterine bleeding, endometriosis)
Other effective contraceptive options are not suitable or not tolerated
The person is young, does not smoke, and has no additional vascular risk factors
Migraine aura is infrequent and stable
The decision is made after a careful discussion of risks and benefits, with informed patient consent
In these cases, it may be reasonable to choose:
The lowest effective estrogen dose
Close follow-up
Ongoing reassessment if migraine patterns change
For many people, progestin-only or non-hormonal contraceptive options remain the safest first-line choice. But when estrogen is being considered, the decision should be made collaboratively, taking into account migraine history, overall health, personal preferences, and treatment goals.
If you have migraine aura and are considering contraception, we can help advise you on the options that best balances safety, effectiveness, and quality of life.
What should I do if my migraine aura becomes more frequent after starting estrogen-containing contraception?
What should I do if my migraine aura becomes more frequent after starting estrogen-containing contraception?
If migraine aura becomes more frequent, more intense, lasts longer, or changes in character after starting an estrogen-containing contraceptive (such as a combined pill, patch, or ring), the estrogen should be stopped and you should contact your doctor.
An increase or change in aura after starting estrogen may signal that the medication is not a safe option for you, even if it was initially felt to be reasonable.
In this situation:
Stop the estrogen-containing contraceptive
Use an alternative form of contraception in the meantime
Seek medical review to reassess migraine symptoms and contraceptive options
This recommendation is precautionary - out of abundance of caution. While the absolute risk of serious complications remains low, a change in aura pattern suggests a shift in neurological risk, and continuing estrogen is not advised until you are reassessed medically.
After reassessment, most people can safely transition to:
A progestin-only contraceptive, or
A non-hormonal option
If you notice new neurological symptoms that are sudden, severe, or do not resolve, seek urgent medical care.
Disclaimer
Disclaimer
This material is provided for educational purposes and does not replace independent clinical judgment or institutional protocols. Management decisions remain the responsibility of the treating clinician.
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