Migraine Aura

Migraine Aura Definition: Migraine aura is a complex aspect of migraine marked by short-lived episodes of reversible symptoms involving vision, sensation, or the central nervous system.
Relation to Migraine: It usually happens before a headache, acting as a warning sign before the full migraine attack begins.
Variability: The symptoms and duration of aura differ among individuals and can even vary from one episode to another in the same person.
Common Symptoms: Visual issues are frequent (over 90%), but it can also involve sensations, language problems, and motor symptoms.
Duration: On average, a migraine aura lasts around 30 minutes, ranging from a few minutes to up to 4 hours for some.
Pathophysiology Implications: Aura's presence in migraines suggests a complex interplay of factors contributing to migraine development.

Genetics of Migraine Aura

Genetics of Migraine Aura:
Heritability: Studies show a higher heritability (65%) for migraine with aura compared to migraine without aura (52%).
Family Risk: Close relatives of individuals with migraine, especially with aura, have increased risks, indicating a genetic component.
Genetic Mutations: Specific genetic mutations, like in the KCNK18 gene, are linked to migraine with aura and influence its occurrence.

Brain Blood Flow: Reduced blood flow in the brain is observed during migraines, extending beyond aura regions.
Ischemia Threshold: Despite blood flow changes, it usually doesn't reach a critical threshold for ischemia, aligning with the infrequency of severe complications.
Recruitment of Ischemic Tissue: Some migraineurs with aura may have increased recruitment of ischemic tissue, potentially leading to larger infarcts.

Cortical Spreading Depression (CSD): A phenomenon involving slow brain activity spreading, potentially triggering migraine symptoms.
Neurotransmitter Release: CSD leads to the release of substances contributing to pain and other symptoms.
Therapeutic Approaches: Medications targeting specific substances released during CSD may offer relief for migraine.

Silent Aura Hypothesis: There's a hypothesis suggesting that aura, even without visible symptoms, might still play a role in initiating migraines.
Noneloquent Cortex: The aura mechanism could be active in parts of the brain not responsible for noticeable symptoms.

SEX HORMONES AFFECT IN MIGRAINE AURA

Prevalence: Migraine, with or without aura, affects both women and men equally.
Hormonal Influence: Hormonal changes, especially related to estrogen, may influence the occurrence and characteristics of aura.

PATENT FORAMEN OVALE AND MIGRAINE

PFO Association: The presence of a specific heart defect (PFO) might be linked to migraines, especially those with aura.
PFO Closure: Closing the PFO might have benefits for some individuals, particularly reducing days with migraine aura.

MIGRAINE AURA AND STROKE

Association with Stroke: Studies suggest a link between migraine with aura and an increased risk of stroke, possibly involving shared mechanisms.
Perioperative Stroke Risk: People with migraine, especially with aura, might have a higher risk of stroke during certain medical procedures.
Hormonal Contraceptives: Women with migraine with aura using hormonal contraceptives might have a higher risk of ischemic stroke.

PSYCHIATRIC COMORBIDITIES WITH MIGRAINE AURA

Association with Mental Health: Migraine with aura is associated with conditions like depression, bipolar disorder, and panic disorder.
Unique Findings: Interestingly, those with migraine aura without headaches might have different rates of mental health issues compared to those with both symptoms.

IMPLICATIONS OF MIGRAINE AURA FOR CLINICAL MANAGEMENT

Triptan Responsiveness: Medications called triptans may be less effective for migraine attacks with aura.
FDA-Approved Treatment: A specific treatment involving magnetic stimulation is approved for acute migraine with aura.
Ketamine Use: While not widely used, ketamine might be considered for migraine with prolonged aura.
Stroke Risk and Oral Contraceptives: Women with migraine with aura using hormonal contraceptives may have a slightly increased stroke risk, but the absolute risk is considered small.