Treatment For A Migraine With Aura

It's Time To End Your Auras...

The Short Answer

When considering the most appropriate treatment for a migraine with aura, it is best to try a number of potential options.

There may be separate solutions for your migraine and for the aura, with the aura completely preventable, while the migraines could be reduced in severity and frequency.

If you suffer with a migraine with aura, it is absolutely essential that you put together a vigorous treatment plan – especially considering the proven connection between aura and stroke (The BMJ). 

Understanding The Aura…

We discussed in previous articles that current medical thinking separated the migraine and the aura as two separate neurological events.

This was partly because you can suffer an aura both with or without a migraine afterwards.

You can even suffer the aura during the main part of the migraine headache.

This suggests that while they may be heavily linked, not least because they carry similar triggers, they do seem to behave somewhat independently.

We then looked specifically at what caused an ‘aura’, since that is what differentiates this type of migraine from any other and very often the aura is actually the most dangerous element.

We also looked at what causes auras in more detail and the role of ‘cortical spreading depression’.

In short, aura are believed to be caused by a wave of electrical silence that passes through your brain. The big danger is that this sudden shutdown and rebooting of your cortical neurons (neurons are what sends the electrical messages) can also cause a reduction of blood flow to your brain. (Cephalalgia – The International Headache Society)

All of this results in an increased risk of stroke and other cardiovascular issues, if not treated.

The good news however, is that while a migraine is considered incurable, the aura’s are described as being ‘fully-reversible’ in The International Classification of Headache Disorders 3rd edition. https://ichd-3.org/

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Treatment For A Migraine With Aura – How To Treat The Aura…

Current guidelines suggest the same treatments for ‘migraine with an aura’ as for ‘migraine without an aura’. This is perhaps not surprising for two reasons –

  1. Most migraines/ auras are highly personal in nature, meaning what works for one person is in no way guaranteed to work for anyone else.
  2. The theory around how aura’s form is relatively new, meaning research into how to combat them in isolation is fairly limited.

Since new theories were formed on how auras were caused, more  research has been carried out into how potentially to combat the aura.

This research revolves around combatting either the defective blood platelet theory or the newer theory of electrical silence known as ‘cortical spreading depression’.

As always, we’ve included links to the scientific data should you be so inclined (and have any desire) to read them.

Natural treatments tend to be the first choice for getting rid of migraine headaches, but when it comes to the aura, these are frequently ineffective.

When treating an aura, the most common treatments are chemical.

There are 4 potential treatments that work specifically well for auras…

Aspirin (Acetylsalicylic Acid)…

Aspirin was used for its potential to regulate blood platelets and migraine aura prophylaxis. It was a small study of just 49 patients with each being given 80mg of aspirin daily.

However, the results were very encouraging – with auras being reduced in 39 of 42 cases (that’s 93%!). Not only that, but 48% (20 people) found their auras completely stopped. (The Lancet

A second retrospective study of 203 patients that were suffering migraines with aura saw 95 of the trialists (47%) reporting a significant reduction in aura duration from an average 36 minutes to an average 22 minutes (European Neurology). 

Glutamate Receptors Inhibitors…

Glutamate Receptors Inhibitors (especially NMDA receptor antagonists) can allegedly help to prevent the continuation of ‘cortical spreading depression’, which is thought to be a major cause of auras.

Two particular trials attempted to measure the effectiveness of ketamine (an NMDA receptor antagonist).

The first published by The American Academy Of Neurology was tested using ketamine (and MDN receptor antagonist) on prolonged aura in just 11 patients with a hemiplegic migraine (and aura). The result saw 5 of the 11 reporting that their auras were significantly shorter. 

The second study (published in ‘Neurology’) saw 18 subjects finish a trial measuring 25ml intranasal ketamine against midazolam, again testing patients suffering prolonged auras. This time the ketamine managed to reduce the severity, but not the length of the auras being suffered. The patients on midazolam reported no change (ie the midazolam was ineffective). 

Levetiracetam…

A third potential option is a drug known as Levetiracetam. This is a drug traditionally used to treat epilepsy. A small trial of 16 patients suffering a migraine with aura saw a reduction in the number of attacks and the complete disappearance of aura in 7 out of 16 cases (43%). (Clinical Neuropharmacology

This trial also saw a reduction in the length of aura in the remaining patients.

Ginkgolide B…

This is a herbal extract taken from the leaves of the Ginkgo Biloba tree. It has been tested twice for the prophylactic treatment of migraines with aura.

The first test led to both a reduction in the number of aura attacks and the aura duration. (Neurological Sciences Journal

The 2nd trial followed a similar result, with average aura duration dropping from 34 minutes to 22 minutes and similar reductions in severity. In 18% of patients, the auras disappeared altogether. (Neurological Sciences)

Treating A Migraine With Aura – How To Treat The Headache…

Treating the headache element of a migraine with aura is a fairly generic process of trying different treatments and working out which work best for you.

Treatment then a mixture of medication, electrical and natural treatments.

Medications.

These split into 2 categories – medications for relief and medications for prevention. If your migraines with aura happen for more than 15 in a month, then you should avoid meds at all costs since they may lead to ‘rebound headaches’, where your meds actually start causing the migraines.

Migraine Relief…

Painkillers. Aspirin has already shown it’s value in treating the aura, but can also provide pain relief during the headache phase too. Ibuprofen is another option for headaches, although caution should be taken if taking these regularly (The Dangers Of Ibuprofen Usage)

Triptans. These are prescription drugs such as sumatriptan and rizatriptan (brand names such as Imitrex, tosymra and Maxalt).

However, several clinical trials have shown they are effective in providing pain relief from the headache element – but NOT if you take them during the aura beforehand.

When taken during the initial aura, they were shown to have no effect on the pain levels. This is worth considering if you suffer from migraines with aura since the auras are often your 1st indication of an impending migraine.

Anti-Nausea Drugs (chloropromazine etc). These are effective if you suffer with vomiting or nausea during your migraine.

Opioids. Opioids such as codeine, tramadol or morphine can be given in the case of extremely painful migraines.

Dihydroergotamines (such as Migranal). These are sometimes given for long-lasting migraines, but they can also make your migraines worse, rather than better.

Preventative Medications…

Preventative medications aim to reduce the number of migraines you suffer, with or without an aura.

These include –

  • Antidepressants.
  • Anti-Seizure Drugs
  • Botox Injections
  • Blood Pressure Meds
  • CGRP (Calcitonin Gene-Related Monoclonal Antibodies

Other Common Treatments For A Migraine And The Aura…

Magnesium Supplements.

Magnesium can act as in intracellular mediator and magnesium sulphate was found to outperform a placebo – but only for migraines with aura. Patients with migraines that didn’t have aura saw no difference in symptoms, while those with an aura saw a significant improvement in all their symptoms. (The International Headache Society).

Peppermint Oil (Aromatherapy).

The high level of menthol (44%) in peppermint oil has been clinically trialled and proven to offer migraine headache relief.

TMS (Transcranial Magnetic Stimulation).

This procedure involves using a single electrical pulse to disrupt the wave of cortical spreading depression that is thought to cause auras.

Many TMS machines are now approved for medical use at home, although some require a prescription before using.

Among the trials advocating their use, one published in The Lancet Neurology saw 267 patients suffering from migraines with aura inducted. There were two groups (one a sham not actually given TMS treatment) and the other given TMS.

The result was the 39% were pain free within 2 hours with the TMS machine, while this was just 22% in the ‘placebo’ group.

Another trial in The Journal of Headache and Pain (Clarke et al) showed a 75% decrease in pain in all migraines (with or without aura), while in those who suffered a migraine with aura, the relief was 100% and almost immediate.

It should be noted that amongst the considerable number of clinical trials on TMS machines, a couple of the trials do question whether their effectiveness every time, but that is to be expected as the effectiveness of any migraine treatment is a largely personal experience.

What works for you is never guaranteed to work for someone else, especially when we are looking at altering electrical brain activity.

Overall however, results for TMS machines have been sufficiently successful that they are now accredited in most modern countries for the treatment of migraines.

What is interesting when it comes to finding a treatment for a migraine with aura is that they appear to be even more effective than just treating normal migraines (without aura).

Other Successful General Migraine Treatments Include…

Hot/ Cold Therapy.

Applied to your neck or forehead, switching cold to hot can have both an easing and a numbing effect.

Hypnosis/ Self-hypnosis.

This can convince your brain to block some of the pain signals. It has remarkable clinical data behind it.

Silence.

Perhaps the oldest and the best. Lay down in a dark, quiet room.

Food.

The wrong foods can be a trigger, but the right comfort foods can also help with energy, hydration and feeling better.

Caffeine.

Some sufferers have reported feeling better following a cup of coffee. This is thought to be down to the caffeine increasing the effectiveness of paracetamol (acetaminophen) and aspirin.

Massage.

This has been proven to help with neck/ shoulder pain in particular, that can often be a contributing factor to migraine development and severity. The relaxing qualities certainly help too.

Herbs.

Feverfew and Butterbur in particular are accepted as potential options for reducing the frequency of your migraines.

Relaxation Techniques.

This includes meditation and bio feedback and is great for reducing the stress that a top trigger of migraines with aura.

Sickness.

Believe it or not, making yourself sick at the beginning of a migraine (especially if you are feeling ill) can actually make you feel a lot better.

The Final Word –

Treating migraines with aura is a delicate, specialised process. Successful treatment relies on treating both the aura and the cause of the migraine.

Accepting that they are separate, but connected, entities and understanding what might cause the aura to form will help you greatly.

Finding the right treatment for a migraine with aura however, is still a balancing act between learning/ avoiding your triggers, taking steps to prevent future migraines and treating them properly when they arrive.

No single treatment can ever achieve complete success, but by trying a few treatments, you will eventually find the best few that work for you.

Your treatment plan should then evolve to make the most of those treatments that really made a dent on your migraines. With really good management, you should even be able to cut out the aura phase altogether and be left with just a reduced number of migraines – hopefully very greatly reduced.

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References Used –

1. Mahyar Etminan, Bahi Takkouche, Francisco Caamaño Isorna and Ali Samii. (Jan 2005). Risk of ischaemic stroke in people with migraine: systematic review and meta-analysis of observational studies. The British Medical Journal.
2. 3. M Lauritzen. Cortical Spreading Depression in Migraine. Cephalalgia The International Headache Society.
3. The International Classification of Headache Disorders 3rd edition. https://ichd-3.org/
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5. Turk W.E, Uiterwijk A, Pasmans R, Meys V. Ayata C, Koehler P.J. (2017). Aspirin Prophylaxis for Migraine with Aura: An Observational Case Series. European Neurology.
6. H. Kaube, J. Herzog, T. Käufer, M. Dichgans, H.C. Diener. (July 2000). Aura in some patients with familial hemiplegic migraine can be stopped by intranasal ketamine. Neurology.
7. Shazia K. Afridi, Nicola J. Giffin, Holger Kaube, Peter J. Goadsby. (Jan 2013). A randomized controlled trial of intranasal ketamine in migraine with prolonged aura. Neurology
8. Filippo Brighina, Antonio Palermo, Antonina Aloisio, Margherita Francolini, Giuseppe Giglia and Brigida Fierro. (Nov 2006). Levetiracetam in the Prophylaxis of Migraine With Aura: A 6-Month Open-label Study. Clinical Neuropharmacology.
9. Giovanni D’Andrea, Gennaro Bussone, Gianni Allais, Marco Aguggia, Florindo D’Onofrio, Maurizio Maggio, Franca Moschiano, Maria Gabriella Saracco, Maria Grazia Terzi, Vittorio Petretta & Chiara Benedetto. (May 2009). Efficacy of Ginkgolide B in the prophylaxis of migraine with aura. Neurological Sciences.
10. Gianni Allais, Giovanni D’Andrea, Maurizio Maggio & Chiara Benedetto. (May 2013). The efficacy of ginkgolide B in the acute treatment of migraine aura: an open preliminary trial. Neurological Sciences.
11. ME Bigal, CA Bordini, SJ Tepper, JG Speciali. (June 2002). Intravenous Magnesium Sulphate in the Acute Treatment of Migraine Without Aura and Migraine with Aura. A Randomized, Double-Blind, Placebo-Controlled Study. Cephalalgia. International Headache Society.
12. Richard B Lipton MD, David W Dodick MD, Stephen D Silberstein MD, Joel R Saper MD, Sheena K Aurora MD, Starr H Pearlman PhD, Robert E Fischell ScD, Patricia L Ruppel MPH and Peter J Goadsby MD. (March 2010). Single-pulse transcranial magnetic stimulation for acute treatment of migraine with aura: a randomised, double-blind, parallel-group, sham-controlled trial. The Lancet Neurology.
13. B. M. Clarke, A. R. M. Upton, M. V. Kamath, T. Al-Harbi & C. M. Castellanos. (October 2006). Transcranial magnetic stimulation for migraine: clinical effects. The Journal of Headache and Pain.

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