Migraine with and without aura

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Migraine is a recurrent neurological disorder with a broader attack than head pain alone. Premonitory symptoms can include yawning, mood change, neck discomfort, thirst and food craving; headache is followed by a postdrome of fatigue or cognitive slowing. In adults, untreated headache commonly lasts 4–72 hours and has at least two of unilateral location, pulsating quality, moderate or severe intensity, or aggravation by routine activity, together with nausea or vomiting or both photophobia and phonophobia. Children may have shorter and more bilateral attacks. Ask about disability, work and caring impact, frequency of all headache days, acute medicine use, sleep, menstruation and family history. Normal examination between typical attacks supports a primary syndrome but does not replace deliberate red-flag screening.

Aura reflects transient cortical dysfunction and is diagnosed from evolution, duration and reversibility. Common visual aura includes a gradually enlarging scintillating scotoma; sensory aura may spread from hand to face; dysphasic aura affects language. Different symptoms may occur in succession and each typically lasts 5–60 minutes. Urgent or specialist assessment is appropriate for motor weakness, double vision, visual symptoms affecting one eye only, poor balance or reduced consciousness, because these are not routine aura features in NICE guidance. TIA more often produces sudden negative deficit at onset, while focal seizure is often briefer, stereotyped and may have altered awareness, but overlap requires clinical judgement. Retinal disease, dissection and cerebral venous thrombosis should not be hidden beneath the word aura.

Migraine frequency exists on a spectrum. Episodic migraine has fewer than 15 headache days monthly; chronic migraine crosses the 15-day threshold for over 3 months with migraine features on at least 8 days. Medication overuse, depression, anxiety, sleep disorders and other pain can amplify disability and should be assessed without implying that symptoms are psychological. Menstrual-related migraine is suspected when attacks cluster from 2 days before to 3 days after menstruation in at least two of three cycles, confirmed with a diary. Pregnancy often changes pattern, so a new severe pregnancy headache needs its own secondary assessment. The diagnosis should be revisited if attacks become continuously progressive, awaken the patient in a new way, change after age 50, or acquire systemic or persistent neurological features.

Key points

Migraine is a positive clinical diagnosis: recurrent attacks commonly last 4–72 hours and combine moderate or severe headache with nausea or sensitivity to light and sound.
The pain may be unilateral or bilateral, often pulsating and aggravated by routine activity, but no single descriptor is required when the overall pattern is characteristic.
Typical aura is fully reversible visual, sensory or speech disturbance that develops gradually over at least 5 minutes and usually lasts 5–60 minutes for each symptom.
Positive spreading phenomena, such as scintillation or marching paraesthesia, favour aura; abrupt maximal negative loss, persistent deficit or simultaneous symptoms raise concern for TIA or another cause.
Aura may precede, accompany or occur without headache, and an individual can have attacks both with and without aura across their lifetime.
Use a headache diary for at least 8 weeks when diagnosis or burden is uncertain, recording frequency, duration, severity, associated symptoms, medicines, triggers and menstruation.
Do not image a stable typical migraine solely for reassurance when examination is normal and there are no secondary features; explain the positive diagnosis and safety net instead.
Offer contraception and vascular-risk counselling where relevant: current UKMEC classifies combined hormonal contraception as category 4 in migraine with aura, so it should not be used while safer contraceptive options are discussed.
Diagnose chronic migraine when headache occurs on at least 15 days per month for more than 3 months with migraine features on at least 8 days, while also assessing medication overuse.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Inherited network susceptibility

Migraine is a complex polygenic brain disorder in which inherited differences in sensory, pain and excitability networks lower the threshold for attacks.

Hormonal and physiological modifiers

Menstrual change, sleep disruption, stress, missed meals and illness can alter attack probability without acting as one universal underlying cause.

Individual attack triggers

Light, odour, alcohol and other reported exposures may precipitate attacks in some people, while apparent triggers can also represent early premonitory symptoms.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Premonitory network change
Hypothalamic, brainstem and cortical networks alter before pain, producing fatigue, yawning, mood, appetite and sensory symptoms in some attacks.
2
Trigeminal vascular activation
Trigeminal afferents and meningeal pain pathways release neuropeptides and activate central nociceptive circuits, generating headache and activity-related worsening.
3
Central sensory sensitisation
Brainstem and thalamic processing amplifies light, sound, smell, touch and nausea signals as the attack evolves.
4
Cortical spreading depolarisation
In aura, a slowly propagating wave of cortical electrical change produces sequential, fully reversible visual, sensory or language symptoms.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Migraine without aura

Recurrent disabling attacks lasting hours, with activity aggravation and nausea or light-and-sound sensitivity, support migraine even when pain is bilateral or not described as pulsating.

Typical visual aura

A fully reversible positive or negative visual phenomenon that spreads gradually across the field and resolves within about an hour is more characteristic than abrupt monocular darkness.

Typical sensory or speech aura

Pins and needles that march over minutes, sometimes followed by numbness, or gradually evolving reversible language disturbance can precede or accompany migraine headache.

Atypical aura featureRed flag

Motor weakness, diplopia, monocular visual symptoms, reduced consciousness or impaired balance requires further assessment because it falls outside straightforward typical-aura diagnosis.

Chronic migraine

At least 15 headache days monthly for over 3 months, including at least 8 days with migraine features, defines chronic migraine after alternative causes and overuse are assessed.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Structured headache historyFirst step
Why
Make a positive migraine diagnosis and identify a meaningful change or secondary-headache feature.
Interpretation and limitations
Attack duration, activity aggravation, nausea, sensory sensitivity and reversible evolution support migraine; sudden maximum pain or persistent deficit does not fit a routine attack.
02
Eight-week headache diary
Why
Quantify migraine days, total headache days, acute medication, disability, menstruation and possible triggers.
Interpretation and limitations
Diary patterns distinguish episodic from chronic migraine, reveal medication overuse and provide a baseline for treatment response; isolated associations do not automatically prove triggers.
03
Neurological and funduscopic examination
Why
Check for objective deficit, optic-disc swelling or another clue requiring secondary investigation.
Interpretation and limitations
A normal interictal examination is expected in typical migraine; persistent lateralising signs or papilloedema require urgent investigation rather than routine follow-up.
04
Targeted neuroimaging
Why
Investigate red flags, atypical aura or a substantial change, not confirm ordinary migraine.
Interpretation and limitations
Select CT, MRI and vascular sequences according to the suspected secondary disorder; avoid imaging simply to reassure a stable typical phenotype.
05
Cardiovascular and contraceptive risk review
Why
Identify modifiable stroke risk and medicine or contraception issues in migraine with aura.
Interpretation and limitations
Smoking, hypertension and oestrogen-containing contraception compound vascular concern; discuss safer contraceptive options through current UK medical-eligibility guidance.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Transient ischaemic attack

Abrupt maximal negative loss occurring simultaneously favours TIA, while gradually spreading positive symptoms followed by headache support typical aura.

Focal seizure

Very brief stereotyped positive symptoms, impaired awareness or motor automatisms favour seizure; postictal deficit can further complicate distinction.

Cluster or tension-type headache

Short restless unilateral attacks with autonomic signs suggest cluster headache, while bilateral non-disabling pressure without nausea favours tension-type headache.

Secondary vascular or pressure headache

Thunderclap onset, persistent focal deficit, papilloedema, fever or a substantially changed pattern requires investigation beyond a previous migraine diagnosis.

Additional chapter-specific clues

Migraine mimicRed flag

Sudden fixed deficit, first or worst abrupt pain, seizure features, fever, papilloedema or progressive personality change should move the clinician away from uncomplicated migraine.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01DiagnosisBuild the recurrent attack phenotypeFirst stepA person reports episodic headache with or without transient neurological symptoms.

1Establish duration, frequency, onset speed, pain behaviour, nausea, sensory sensitivity, disability and complete recovery, then compare every feature with previous attacks.
2For neurological symptoms record whether phenomena were positive or negative, gradual or abrupt, sequential or simultaneous, and fully reversible within the expected duration.
3Screen for systemic, vascular, pressure, pregnancy and examination red flags before assigning migraine with or without aura.
4Explain the positive diagnosis, begin a diary when useful and agree separate plans for acute treatment, prevention threshold and urgent reassessment.

02Aura uncertaintyDistinguish transient mimicsVisual, sensory or speech symptoms are new, atypical or incompletely described.

1Clarify field versus one eye, symptom spread, precise onset and duration, associated headache, awareness and whether the same sequence has recurred stereotypically.
2Treat abrupt negative loss, persistent deficit, painful Horner syndrome or vascular-risk presentation through urgent stroke or vascular pathways as appropriate.
3Seek neurological or ophthalmic assessment for motor, brainstem-like or monocular features and choose imaging for the specific competing diagnosis.
4Do not let a later headache retrospectively prove migraine when the transient neurological event itself remains high risk.

03Longitudinal reviewMeasure burden and changing riskMigraine is established but attacks are frequent, disabling or changing.

1Count migraine days, all headache days, acute-treatment days and functional loss over a representative diary period.
2Assess medication overuse, mood, sleep, menstruation, pregnancy plans, contraception and cardiovascular risks alongside headache treatment.
3Recheck for red flags when pattern or examination changes, reserving routine imaging for a defined new clinical question.
4EscalationUse shared decisions to escalate acute or preventive management and define a measurable review point rather than accepting recurring unscheduled care.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Chronic migraine

Increasing attack and headache frequency can produce near-continuous disability, especially when sleep, mood and acute-treatment use become maladaptive.

Medication-overuse headache

Frequent rescue treatment can sensitise pain networks and make headache more frequent, obscuring the original episodic pattern.

Functional and psychosocial loss

Pain, nausea, sensory intolerance and aura impair work, education, driving, caring roles and participation despite normal function between attacks.

Vascular and reproductive decisions

Migraine with aura influences combined hormonal contraception safety and vascular-risk counselling without making stroke inevitable for an individual.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Track monthly migraine days, total headache days and days of acute medicine use, because pain severity alone misses progression to chronic migraine or overuse.
Record disability through missed work, interrupted activity and recovery time, then compare function as well as attack counts after treatment changes.
Review aura phenotype and duration if symptoms evolve; persistent, abrupt or monocular deficits should trigger reassessment rather than diary observation alone.
Revisit contraception, smoking, blood pressure, pregnancy intentions and new vascular risk in people with migraine with aura.
Provide explicit emergency return advice for thunderclap pain, weakness, impaired consciousness, fever, papilloedema symptoms or a major departure from the usual pattern.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Migraine is more than pain

Premonitory symptoms and postdrome form part of the attack biology; recognising them can improve planning and prevents every associated symptom being labelled a drug adverse effect.

Aura tends to travel

Gradual spread across cortex produces evolving visual or sensory phenomena, whereas a sudden fixed negative deficit deserves vascular assessment until a safer explanation is established.

Laterality is not mandatory

Unilateral pulsation is classic but not universal. Bilateral pain can still be migraine when duration, activity aggravation and associated symptoms form a coherent pattern.

A diary tests frequency

Prospective recording is particularly valuable for chronic migraine, menstrual association and medication overuse, where recall over several months is often inaccurate.

Imaging is not validation

Migraine is diagnosed clinically, and a scan does not prove the disorder. Unnecessary imaging can uncover incidental findings that worsen anxiety without improving care.

11Common pitfallsFrequent interpretation and management errors.

01
Excluding migraine because headache is bilateral, non-pulsatile or not preceded by aura despite a strongly characteristic overall attack.
02
Calling sudden monocular darkness or persistent unilateral weakness typical aura without urgent vascular or ophthalmic assessment.
03
Using a previous migraine diagnosis to explain a first thunderclap episode or a substantial new pattern during pregnancy.
04
Counting only severe migraine days and missing the additional milder headache days that meet chronic-migraine or medication-overuse thresholds.
05
Ordering brain imaging to confirm migraine rather than because a specific secondary diagnosis is clinically suspected.
06
Providing a diagnosis without acute-treatment, prevention, contraception and safety-net discussions, leaving the patient dependent on repeated urgent consultations.