Examples of typical and atypical aura in migraine
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"migraine with aura"[MeSH Terms] AND "aura"
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migraine visual aura scintillating scotoma fortification spectrum
Let me read the Bradley and Daroff migraine attack section for details.
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Terminology: "Typical" and "atypical" are not strict ICHD-3 terms, but the textbooks use them the following way.
Typical aura
ICHD-3 defines typical aura as fully reversible visual, sensory, or speech/language symptoms, with no motor weakness. Features common to all of them:
- They develop gradually over at least 5 minutes, and sequential symptoms can follow one another.
- Each symptom lasts 5-60 minutes.
- They are usually followed by headache, or accompany its onset.
- About one-third of migraine patients have aura. Only about one-fifth of them have it with every attack (Bradley and Daroff's Neurology in Clinical Practice, p. 2475).
1. Visual (most common, over 80% of patients with aura)
- Positive phenomena are flashing lights and wavy lines (scintillating scotoma), then a negative scotoma in the same area. These progress slowly across the visual field (Bradley and Daroff, p. 2475).
- Other positive phenomena are fortification spectra (zigzag lines that slowly drift across the field), teichopsia, and photopsias (brief sparks or flashes). Blurred vision can also occur (Rosen's Emergency Medicine, Box 89.3).
- Classically the aura is binocular, affects the central field on one side, and lasts 5-30 minutes (Kanski's Clinical Ophthalmology, 10th ed.).
2. Sensory (second most common)
- Paresthesias (positive) are followed by numbness (negative).
- They are usually unilateral and migrate slowly, typically from the hand up the arm to the shoulder, face, perioral area, and tongue.
- The spread takes about 10-20 minutes. That is slower than a sensory seizure and much slower than a TIA, which is the key distinguishing feature (Bradley and Daroff, p. 2475).
3. Speech/language (third most common)
- Expressive dysphasia, including paraphasic errors, is typically mild (Bradley and Daroff).
Atypical aura
These are the forms that fall outside ICHD-3 "typical aura". They are not always benign, and they are the ones that raise the question of stroke or TIA.
| Type | Features |
|---|---|
| Hemiplegic migraine (familial or sporadic) | Unilateral motor weakness, usually with visual, sensory, or speech symptoms. It evolves gradually and lasts up to 60 minutes (longer in some cases). The familial form is a channelopathy (Rosen's, Box 89.3). Rarely the deficit persists because of a true stroke. |
| Migraine with brainstem aura | Dysarthria, vertigo, tinnitus, diplopia, and altered level of consciousness (Rosen's). From ICHD-3, I recall that these symptoms come without motor weakness, and that ataxia, hypacusis, and bilateral visual or sensory symptoms can also occur. |
| Retinal migraine | Recurrent attacks of monocular visual dysfunction, either positive (scintillations) or negative (blindness), which are completely reversible. Diagnose it only after excluding retinal and ocular causes (Rosen's). |
Other atypical patterns:
- Aura without headache (acephalgic migraine) can be confused with TIA. Kanski and Wills Eye list it under transient visual loss (Wills Eye Manual).
- Aura timing out of the usual sequence: aura can occur during or after the headache phase (Bradley and Daroff).
- Prolonged aura: aura lasting more than 60 minutes. Persistent aura without infarction and migrainous infarction are listed as complications of migraine (Bradley and Daroff, Box 102.2).
- Aura-triggered seizure is also listed as a complication in the same box.
- Other unusual symptoms (from my own knowledge, not retrieved from the library): Alice in Wonderland distortions (micropsia, macropsia), olfactory or auditory hallucinations, and a sense of déjà vu. A 2024 systematic review covers multisensory hallucinations in migraine.
Red flags that suggest something other than migraine aura
- Abrupt onset, or purely negative symptoms (no scintillation or paresthesia progression).
- A new aura after age 40 or a change in the usual pattern.
- Motor, brainstem, or retinal symptoms in a patient with no prior history.
- Aura lasting more than 60 minutes, or a fixed deficit.
Any of these warrants evaluation for TIA, stroke, seizure, or dissection.
Recent evidence
I checked recent PubMed systematic reviews for updates, and none contradicts the textbook descriptions. A 2025 systematic review of what aura looks like (PMID 40597581) and a 2026 review of pharmacological triggers of aura (PMID 41923467) are the most relevant. I read only their titles and metadata, not the full text.
The image library had no matching figure for visual aura.
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