When diagnosing and treating patients with migraine, it is important to have a clear understanding of the symptoms and characteristics that a patient may be experiencing. This is especially true for migraine with aura – the diagnosis is purely clinical, and it is difficult to distinguish migraine with aura from other serious neurological disorders, such as transient ischaemic attack or epilepsy. During his presentation at the 13th annual congress of the European Headache Federation, Dr Michele Viana (Regional Hospital Lugano, Switzerland) provided insights into the clinical features of visual aura symptoms.

Visual disturbances are the most frequent symptom in migraine with aura, with 98% of migraineurs with aura experiencing them. Other symptoms are somatosensory (36% of migraineurs) and dysphasic symptoms (10%).1 Visual symptoms are multifaceted and spread gradually. Migraineurs report a variety of symptoms, that are often complex and multiple symptoms can occur during a single aura.1,2 Dr Viana highlighted the lack of clinical description of the plethora of visual symptoms, and continued with the current description of visual symptoms: zigzag figures assuming a laterally convex shape with an angular scintillating edge leaving scotoma in its wake.3 Results from a prospective, diary-aided study indicated that the five most frequent ‘elementary’, or individual, visual aura disturbances are flashes of bright light, foggy/blurred vision, zigzag/jagged lines, scotoma and phosphenes (small bright dots). Most aura have two visual symptoms and in 85% of aura, symptoms last for one hour or less.1

Dr Viana proceeded by addressing the visual field in which aura occur. Visual aura typically begin at the periphery of the visual field (40%), followed by initiating in one half (27%) or in the entire (25%) visual field. Only 36% of visual aura are reported to occur on both sides of the visual field, indicating that the majority are unilateral.1 Dr Viana alerted the audience that while in most patients visual aura occur in both eyes, there is currently no clinical evidence supporting this observation. As for colours, half of migraineurs report always having black and white (30%) or black and silver (21%) visual aura. The remaining migraineurs described having both black and white and colourful (22%), colourful (18%) or no colour (9%) visual aura.4

Dr Viana concluded by emphasising that migraine with aura is a multifaceted phenomenon and understanding its ‘hundred faces’ is of paramount importance for accurate diagnosis and treatment. Additionally, Dr Viana alerted the audience that an updated list of all evaluated visual symptoms of migraine with aura and their description will be promptly published in the Journal of Headache and Pain.5


  1. Viana M, et al. Clinical features of migraine aura: Results from a prospective diary-aided study. Cephalalgia. 2017;37:979–989.
  2. Viana M, et al. Migraine aura symptoms: Duration, succession and temporal relationship to headache. Cephalalgia. 2016;36:413–421.
  3. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia.2018;38:1–211
  4. Queiroz LP, et al. Characteristics of migraine visual aura in Southern Brazil and Northern USA. Cephalalgia. 2011;31:1652–1658.
  5. Viana M, et al. Clinical features of visual migraine aura: A systematic review. J Headach Pain. 2019; in press.