S5:Ep9 – Everything You Need to Know About Migraine Auras



Voice-over: Welcome to Spotlight on Migraine hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

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One in three people with migraine experience aura, a temporary sensory disturbance that occurs before or during the headache phase of an attack. In this episode, Dr. Jennifer Robblee describes types of auras, along with our current understanding of what happens in the brain during an aura.

Molly O’Brien: Hello, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien.

Today we’re taking a deep dive into migraine with aura. What is aura anyway? Why do we get it? Why do some people not get it? We’re going to answer these questions and more.

And I’d like to introduce our guest, Dr. Jennifer Robblee. Dr. Robblee is a neurologist and headache specialist at the Lewis Headache Center, which is part of the Barrow Neurological Institute. She’s also a member of AMD’s Executive Advisory Board.

Dr. Robblee, thanks so much for joining us today.

Jennifer Robblee, MD, MSc, FRCPC: Thank you so much for having me. I’m delighted to be here.

O’Brien: I’m so glad you’re here with us, too, and we were just chatting about how complex the brain is and how much we continue to learn and all that there is out there. So we’re going to talk, today, a little bit about migraine with aura. You’re going to help us get as much information as possible. So let’s start off with just the basic what is migraine with aura?

Robblee: So migraine with aura is just one part of a very complex disease that’s known as migraine. We think that it’s about one in three people who have migraine also have aura. And you can think of it as, often, a warning sign that you’re about to have a headache start. However, that is a little simplistic because there’s actually a whole bunch of different features to migraine, including something called the prodrome or the premonitory syndrome, which is completely different from aura. So you can have warning symptoms that are not aura just because we like to make things complicated in the brain.

There is a very wide range of symptoms that can be an aura, and it can be anything from visual symptoms, where you see a bunch of flashing lights or spots in your vision; you might see almost like this heatwave; it can be sensations like a numbness or a tingling; it can be problems with your speech, where you can’t find the words, or you’re saying the wrong words, or just you try to speak and no words come out. But everyone’s experience is going to be a little bit different.

O’Brien: And many of us think we might have somewhat of an understanding about migraine and aura. But we were just talking that we think we know, but we don’t really know. So can you tell us a little bit about some of the ways that we can understand a little bit more about migraine? Like the difference between regular migraine and migraine with aura.

Robblee: First off, we don’t completely understand the differences. There’s a lot that we know, but there’s still a lot that we do not know. So we do know that there is a genetic predisposition to getting migraine, and how one person has it manifest in them versus another person can be very different, even if you’re within the same family. There does seem to be a stronger link that if you have a first-degree relative, like your mom or your dad, who has aura, then you are much more likely to have aura.

So in terms of the aura itself, we think of it as neurological symptoms, they’re reversible, and they’re usually very time limited. There’s exceptions to that, like there’s exceptions to everything in medicine, but usually it’s a very distinct presentation. And it often is followed by headache, but, again, not always, and we’ll get into that.

With aura, there’s electrical and blood flow changes that kind of spread and go across the brain. And for instance, visual symptoms are the most common. Your visual center is at the back of your brain. That’s called the occipital lobe. And so we think that these changes kind of spread across that visual lobe area, and that makes you see all these funny flashes of lights and spots as part of your aura.

So there’s a lot of things that we understand. We’ve used science to look at animal models, and there is a whole concept called cortical spreading depression, but we actually don’t even know if that happens in humans. We think it does. And we’re using what we’ve learned based on animal models and the types of testing that we can do in humans. So still a lot that we don’t know. But what happens in aura is very distinct from what happens in the brain during the actual headache symptoms, or distinct from that other warning syndrome that I told you about called the prodrome. Each of those have very different phenomenon in the brain.

O’Brien: It’s so cool to hear you talk about it and kind of giving a visual concept of like, I’m getting aura because I’m getting blood flow and electrical impulses spreading over my brain. That makes it so much easier to understand. So, thank you for that.

Robblee: There’s actually a neurologist who…he was able to track the size change in his aura and the speed at which it grew, and it matched the rate that we think that this spreading wave goes across the brain. So that actual growth and change in your aura likely mimics the speed that those changes travel. So in animal models, it’s about 3 mm/s, but it probably varies a little bit in humans.

O’Brien: That’s so cool. I’m into that. I’m going to have to look that up, right?

So you talked a little bit about the different kinds of aura that we can experience. We also talked a little bit about those visual disturbances that are the most common. But let’s talk about a couple other of different ways that aura…how it can present itself.

Robblee: Like I said, the visual is, by far, the most common. We think it’s about 90% of aura. And so to kind of cover that first, like I said, you might see things like sparkles or flashes of light, you might see zigzags, you might have a part of your vision that just looks like it’s sort of smudged out. Or it may be a combination of those things, your vision looks smudged out, but there’s all these like zigzags and flashes around it.

There are symptoms that can be visual, like blurry vision, and we don’t know if that’s aura. For some people, that may be aura. But for some other people, that could be what we call an autonomic symptom, where it’s because migraine has made your eyes dry or the size of your pupil change. So there’s other things. So it’s not just because you have a visual symptom, it does not necessarily mean that it is aura.

Similarly, you can get things that affect other parts of your body that are neurologic symptoms. So that numbness and tingling, often that sort of starts like in your face, can go into your tongue, and might sort of spread, go down your face, into the hands and arms, sort of travels up. And you could have, as I mentioned, some problems with your speech.

And for extra fun, for some people, you might have all three of those happen, and they’re often sort of one after another. And again, you can kind of imagine it sort of spreads across the part of your brain for the vision, then goes into the part of your brain for sensation, then goes into one of your language centers. And so you can kind of imagine those steps happening.

Those three types of auras, those are what we call typical aura. So they’re the more common ones. They’re the ones that we understand better. There’s also what we call brainstem aura, hemiplegic migraine, and then retinal aura.

Now, the brainstem, this used to be called a basilar migraine because the brainstem is this lower part of the brain, at the back of it. And the basilar artery is one of the arteries that give blood supply to that area. And so a lot of the symptoms in a brainstem aura could come from that area of the brain, though it’s actually quite controversial if it does because, really, when you look at those symptoms, a lot of them could be coming from the higher center, the brain where we know that the other types of aura typically come from.

So it can be everything from vertigo, double vision because your eyes aren’t moving properly, hearing loss, there’s even been loss of consciousness that’s been reported. So it’s quite a wide spectrum. But again, it’s sort of a complicated one to diagnose because there’s also this entity called vestibular migraine, and the vertigo in that is not felt to be aura. So you can have vertigo as part of migraine, but not necessarily have it be aura as well, again, because we like to make a complicated.

There’s also something called hemiplegic migraine, and that’s where half of your body goes weak during the attack. So you might notice that you have a facial asymmetry, where just that side of the face isn’t activating, you might have difficulty using the arm or walking. And that would be just half the body, it would not be both sides. Classically, those are actually from some very specific genetic syndromes. So it would run in your family.

But there are forms that are not genetic. However, again, to make it complicated here, sometimes because of the numbness, you may not be able to feel that side of your body very well. So it may feel heavy, you may sort of hold your face funny, and it may look asymmetric. But it’s not that it’s weak, it’s that you’re actually abnormally contracting that side because you can’t feel your face, so you’re holding it weird. And so it can scare people into thinking you have this rare form of migraine.

But if you’re able to have someone like myself actually examine you during it, the features actually aren’t consistent. So again, really important. If you think you have something like this, videotape it so your neurologist can see it. It will really help them differentiate what type you have.

And then finally, there’s what we call retinal aura. Now typically, when you have an aura, it actually comes out of both eyes because the back of your brain, each half of it, it basically does one side of your visual field. So that means your left eye is not just the one seeing it if it’s sort of on that side. It means the left half of both eyes are seeing what’s over here.

If you have a retinal aura, that it’s coming truly from just one eye, I would say a huge proportion of people who have aura think it’s coming out of one eye. But if you actually do a test in the middle of your aura, you will find that you have some of the aura affecting both eyes. And so that tells you it’s coming from the back of the brain and not from the eye.

If it’s coming from the eye, then you want to do some more workup. So it’s really important to differentiate that. It’s exceedingly rare. I can think of one person that I was ever very convinced it was truly a retinal aura. So for most people, it’s going to be both sides.

O’Brien: Wow, it’s so fascinating to learn about and so much to learn about, right?

Robblee: I know, I’m like, okay, how do I keep this simple? Because there’s so much to it, and there’s so many nuances that are actually very important to how you diagnose it and then how you manage it.

O’Brien: Absolutely. I think that’s a really good tip, though, that if you do have some facial distortion or other symptoms that don’t seem quite right, to record it, to give to your doctor.

Robblee: Documenting. And especially for something where there’s something that visually someone can see, photo and/or video is so useful when people can bring that in for me. It’s so rare you’re going to have an attack in front of me.

O’Brien: That’s true. That’s true. So record it. That’s great advice.

So let’s talk a little bit about what we know about aura and timing. We know that aura doesn’t always mean a headache is coming, but a lot of the time it can for people. So let’s talk about that timing. How long can an aura last? And then what happens in relation to headache?

Robblee: So we have criteria that help us diagnose all of our different headache disorders. We have what’s called the ICHD-3, and it’s got very like distinct criteria that we use clinically. But originally, it’s meant more for research to make sure that we’re very consistent with how we’re diagnosing things.

So per those diagnostic criteria, an aura should last anywhere from 5 minutes up to 60 minutes. Can the aura be a little bit shorter? Sure. Is it something that lasts seconds? Probably not. We don’t know. So if you just have some sparkles for a few seconds, is that an aura? We don’t actually know. Perhaps it’s the same phenomenon or perhaps it’s something else that’s just giving some sparkles in the vision momentarily.

And then let’s say it’s goes 2 hours, 4 hours. Is that still an aura? Probably. But at what point is it no longer an aura and something else? We have entities where it says if it’s gone on for a week, you need to make sure it’s not a stroke. But I’m probably not going to wait a week to make sure that’s not a stroke.

And if you start to have like repeated episodes, like every day you’re having 1 to 2 episodes and several days in a row, again, there’s something in the manual where you’re sort of worried about that as well. But if you have an attack that goes on for 5 hours, it’s in an aura, all we have is that’s probable migraine with aura. So we have a lot around that. But there’s still a lot of, again, unknowns and a lot of sort of nuances of what do you call this.

Before you have the actual headache is classically when the attack is going to start. So as I said, often, for people, it’s a sort of warning sign; however, you can absolutely have it where the aura starts and the headache starts at the same time, or you could have the headache start and then somewhere during the attack, when headache’s already established, the aura could then start. And then you can also have aura where you have just no headache at all.

So all of those different things are possible. And because all of those are possible, it’s also been difficult, in the science, to totally understand how the headache and aura are actually linked. Because if it was originally thought to be the warning, we used to think, well, then it must be that it’s triggering headache, but, clearly, that’s not always true. So there’s a lot there that we don’t know for sure.

Also interestingly, as some people tell me, when I have my aura, that’s when I know I’m going to have my worst attack. Those are like the really severe ones, like I got to treat those hard.

And then other people will come in and say, yeah, you know when I have the aura, I’ve got this sort of mild, achy headache that comes with it. But yeah, really the aura is the bad symptom. The headache, whatever, I can ignore that. It’s just a mild one.

So it doesn’t have to be a severe headache. Sometimes the headache itself doesn’t even really meet, technically, the migraine criteria, but because it’s happened with aura, it’s clearly a migraine phenomenon. So there is so much variability, and you may have an aura for some of your attacks and no aura for some of your other attacks. So yeah, lots of variation there, interestingly.

O’Brien: We’ll follow up with that, kind of continuing down that line. Because sometimes you can have aura, sometimes you don’t, sometimes you have the headache, sometimes you don’t. But I’m curious if you have migraine with aura, does that mean you always have migraine with aura, or do you just have migraine? Like how do we…does that make sense? Like do we have…so do you develop it later in life?

Robblee: You can definitely have both, and it could just start with one, and then transition into the other, or have it change over the course of your lifetime. Absolutely. There’s no really completely consistent pattern.

One pattern that we do commonly see is for people who do have migraine with aura, as they age, a good proportion of them will lose the headache part of it but still continue to have the aura phenomenon. So that it is a pattern that we often see in people. But yeah, any of the above possible.

O’Brien: So it can fluctuate over time.

Robblee: Absolutely. Yeah. And just migraine, in general, itself can.

O’Brien: My goodness.

Robblee: I know. We don’t keep this very consistent. It’d be nice with just a nice cookbook, here’s what happens. But no. Everyone’s individual with this.

O’Brien: Well, it’s so cool to get more information. And even though we don’t have solid answers, it’s good to have some answers. Because so many people are curious about these questions.

Robblee: Absolutely.

O’Brien: So again, we’re glad that you’re joining us today.

I wanted to ask, as well, kind of going along those lines, if you normally have migraine with aura and your aura is primarily visual, can you develop different types of aura down the line?

Robblee: I’ve definitely seen it happen. I don’t know that we’ve got good studies on it, at least none that I can think of, off the top of my head. But you know, I’ve seen it.

However, if you have a pretty classic, what we call a very stereotyped aura, so it’s almost always the same, and then you get something very different as part of your presentation, I’m going to want to assess that a little bit more cautious than someone who says, sometimes my aura’s like this, sometimes my aura’s like this. Oh, I haven’t had this one before, but I have some variation.

So, again, it depends on what your overall pattern and clinical picture looks like. If it’s a change from what your baseline is, especially if your baseline is very consistent, you want to be a little bit more cautious in that scenario. But it definitely is possible.

O’Brien: Good to know. So, we talked a little bit about how aura was once thought of as like a warning sign, but that’s not necessarily always the case. So my question is, too, because it can be a warning sign, if people are in tune with their body, can that help them manage a migraine attack? Or does it just kind of like everything’s up in the air because we don’t know if we’re going to get an attack.

Robblee: So I think where it’s useful is if you have a hard time knowing if your attack, your headache portion of the attack is going to turn into a full-blown migraine attack, and you know you only want to treat so many of those because you’re worried because I’ve only got nine of my triptans this month. So is this one that I’m going to need to treat, or is this just a mild headache that’s going to go away a few minutes after it starts?

So if you have the aura, and that typically then warns that you’re going to have a clear migraine attack, it will help you know that, hey, yeah, this is when I need to treat. And that’s important because the earlier you get your rescue medication into you, the better it’s going to work, especially that first half-hour/hour is really the golden time that you want to treat. So I think it’s helpful in that way.

We do have some studies on triptans showing that taking them during the aura does not seem to change the length of the aura, but it still does help the headache if you take it earlier. And we do know that Ubrelvy (ubrogepant), which is one of those new gepants that have come out, it’s been studied to take it during the prodrome. So there seems to be suggestion that treating during the prodrome may be helpful, but, again, whether or not that works during the aura, we still need more there.

There’s not a whole lot that we have good evidence on for clearly treating the aura itself. There’s a bit of evidence, actually, for magnesium. And one of our neuromodulation devices, which is a trans magnetic stimulator, there’s some evidence for that for migraine aura. But we’re kind of limited otherwise. There’s a lot of things…like if you come to me and your main symptom is aura, there’s things we’re going to try, but we’re getting off-label with that.

O’Brien: Okay, okay. Well, that’s good to know. It also can be hard because not everybody recognizes what stage they’re in of their attack. They might not know if they’re in the prodrome. They might not know if they’re in their aura. So that can be hard when you’re trying to decide when to take your medication or treat it if you don’t know where you’re at until you’re deep into the headache portion.

Robblee: Exactly. So usually in that sort of scenario where you’re just never sure how to treat, you want to make sure that you have a few more options. So for instance, we don’t think the gepants cause medication-overuse headache, which is something that happens when you take most rescue medications more than about 9, 10 days a month.

So let’s say your triptans work, and your Ubrelvy works, well, then, we’ll let you treat some of your days with the triptans and some of your days with the Ubrelvy, so then you’re able to cover more, and you don’t feel like you’re as limited. And you may find, hey, this type of attack responds better to this one. And this type of attack responds better to this one. And actually, this attack responds to the combo of the two. So it, again, just gives you a little bit more control back.

But the other thing is track it. So if you’re like, you know what, I feel like every time I start like yawning and feeling really tired, I notice in a few hours, like I start to get nauseous, and then I have my aura start. Okay, well, maybe, actually, that for you is the yawning and the tiredness is actually a prodrome, and that’s a warning sign even before your nausea and your aura. And so you may want to actually start to treat even during that time, or at least try treating to see if that works for you.

So tracking to see if your symptoms are reliably a predictor, and then using that to tell you that, yes, this is a migraine attack, and then get your treatment in earlier can be helpful.

O’Brien: It’s so funny because I’ve had migraine my whole life, and everyone says to track it. And when you do it, you’re just like, oh, like I got a track. And it’s so frustrating for me to hear people say track it, but it’s so useful. So again, and I’ve said this…

Robblee: Again when you track, though, people go way overboard with what they track. Choose one thing you’re going to focus on because otherwise it becomes a full-time job. So if you’re trying to figure out if it’s your yawning, your tiredness, track every time you have yawning and tiredness, and then is there a headache? And that’s all I want you to track. Don’t do anything else. Just answer that one question.

Or if you’re trying to figure out, okay, well, how often are your bad attacks versus your good days versus your no-headache days, do something simple like the stoplight diary, where red days are bad, yellow days are sort of in between, green days are good. And I purposely actually differentiate good days and no-headache days, so you leave your no-headache days blank. And then great. We do that for a month or so. And unless there’s a reason why we want to continue, either you like doing it, or we’re trying to track something specific, maybe that’s all we need just to get that baseline.

So again, I think tracking is super important, can be extremely helpful, but not to the point that it’s a burden, and it’s actually just more stressful. So you should be doing it for a purpose or it’s just a routine that you feel works for you.

O’Brien: I think that’s such a helpful advice because it can become a burden, and but it is so useful to have that information so you can help in what…it’s so valuable. And I love the fact that track one thing at a time. Don’t try to track the weather, the food, your sleep, and yawning. So that’s super-duper helpful advice.

Robblee: And I personally recommend not tracking your triggers, unless you have something that you’re really convinced is very much associated with your headaches. The same way you might be tracking that yawning and that tiredness is a warning, track that one trigger. If it’s something very consistent, perhaps try to take it out.

But if it’s like the weather, you can’t change that. So all you’re going to do is realize the weather is changing, and now you’re waiting for that awful attack to happen. Can it maybe tell you, okay, I might be a little bit more cautious about scheduling something important? But otherwise, you’re not going to be able to change it. So instead, know your warning symptoms and your first sign, so you can just treat it as early as possible and get rid of that attack.

And if your medications aren’t working, then you need to get better rescue medications. The goal is to have a treatment that works within an hour or two. So if your medications aren’t working that fast, talk to your doctor. Plus, you may just need a preventive medication, or if you’re already on one, you may need one that works better.

So spending your time looking for a trigger, especially one you can’t change, I think actually just causes more anxiety and, again, more disability from the disorder, especially when you don’t have control over it.

O’Brien: Absolutely. That is very helpful advice. And maybe we will make a separate podcast about that.

Robblee: There’s so many conversations. We can go on so many tangents.

O’Brien: I know. I know. I love it. I love it. And I appreciate you sharing your knowledge because that is such good advice.

All right, let’s get back on track here to talking migraine with aura.

Robblee: We’re talking about aura, right?

O’Brien: Yeah, yeah, yeah. Which again, tracking is important for every type of migraine and can really be beneficial. But we’ll get back on track with the aura questions.

So when it comes to aura, are there any concerns? Are there any red flag symptoms or warnings that people should know about?

Robblee: Yeah. So one of the reasons why we worry about aura in particular, is, especially if you don’t have all the details or you’re not comfortable with the spectrum of what aura can look like, it can look like a stroke or a transient ischemic attack, a TIA, which is basically what is like a momentary stroke, but the full stroke doesn’t happen. So your brain is able to sort of stop the event before it happens. So the two can look very similar.

In a stroke, that’s where, basically, the blood supply to part of your brain is being cut off, and so you basically have a part of that brain tissue die. And those symptoms come on very suddenly. So it’s snap, symptoms are there. And they’re what we call negative symptoms.

So a negative symptom is when you lose something. So your vision, you lose your ability to see; your sensation, you lose your sensation. So there’s nothing extra, there’s none of those sparkles or zigzags in your vision, you don’t have any of that sort of tingling pins-and-needles feeling. It’s the lack of.

Migraine aura is different in that you can have positive symptoms, negative symptoms, or the combination, and usually they evolve. So as opposed to being boom, just there in a second – like I said, remember the neurologist who tracked his own visual aura. So his visual aura would often start small and then get bigger, bigger, bigger, bigger. So it’s a very classic phenomenon.

Do I have some patients who tell me my aura’s there suddenly? Absolutely, that does happen. The classic is that it sort of grows and gets bigger, maybe then progresses into the numbness and tingling, and that numbness and tingling isn’t like down half your body immediately. It sort of starts feeling, you know, I feel something here. Oh, actually, it’s on my tongue now. Oh, I’m noticing in my fingertips now, too. So it has more of that progression, as opposed to boom, half the body’s numb, and I can’t feel it. So it’s that sort of transition.

And often you have that combo. It’s numb, but you know what, it’s sort of tingly and feels sort of funny, as well. Or that piece of my vision is missing, but around it is just sort of like broken glass and sparkles and zigzags. So it’s often that combo.

So it’s helpful when patients have a very consistent aura, and it’s not their first time because then they start to know, okay, this one’s my aura, I’m okay with this one, versus if they have a sudden onset of new symptoms, and they don’t know for sure what it is. The safest thing is to assume that it’s a stroke, especially if it’s very sudden onset, and it’s this lack of symptoms. However, there’s always going to be the exceptions. I’ve heard of someone having a stroke, sounded more like an aura. So I mean, there is no absolute 100%.

One of the things that also makes it difficult is if it’s purely a loss of speech. If you have only loss of speech and none of your other classic aura symptoms, I would also assume that’s a stroke until proven otherwise. The other thing is, if it goes on and just keeps going on and on and on and isn’t getting better, again, that would be a time to reach out.

Can an aura go for a long period of time? Like I said, yes, we’ve seen auras go on for weeks and weeks before. That’s not normal. You should get imaging in those settings. But those would be times to make it different.

And if it’s your first time having an aura, you want to get assessed. We may not need to do imaging. If you tell me an aura that sounds very classic for migraine aura, then I’m very comfortable with that diagnosis, especially if you have sort of like the classic sort of stepwise across different ones and all those typical features. There’s really nothing else that does that.

But if there’s anything where it’s unclear, atypical, then you may get imaging for your first one. And if you typically have this aura, and suddenly you’re having this brand-new type of aura, again, if there’s anything atypical or worrisome, that’s again when we may get some imaging.

O’Brien: So before we go, we did have a lot of interest in this topic, from our followers on social media, and so wanted to chime in with a few questions from our followers, and thanks for everyone who wrote into us. So this first question is, why might a person with chronic migraine without aura start getting an occasional aura?

Robblee: So it’s a great question. And the honest answer is I’m not going to have a perfect answer for it. So you can think of chronic migraine, which is when you’re having at least 15 headache days per month and, by criteria, also 8 of those days should be migraine. Mind you, some people have a daily headache and even a daily migraine day.

It’s a progression, for people who have episodic migraine, where they may have one headache in year, one headache a month, couple headaches a month, things like that. So you can think of it as a progression where you’re getting more and more what we call sensitization of the brain, so you’re more likely to have those attacks happen.

And as I’ve already said, underlying migraine is this genetic predisposition. So you’ve inherited a whole bunch of different genes. And then all the different things that your body and your brain are exposed to throughout life will make it more or less likely that those genes lead to migraine. And as we’ve already said, you can have both migraine with aura and without aura.

And so perhaps in people where you had migraine, and there was no aura until it became chronic, you had that underlying predisposition all along to be able to have that aura. But as you got into that brain being more sensitized, that brain being more, what we call, hyperexcitable, so there’s more of that irritability at the surface of the brain called the cortex, you’re more likely to get those electrical and those vascular changes making the aura happen. So basically, as it progressed, it sort of just unmasked your ability to have an aura.

O’Brien: Dr. Robblee, I feel like that’s a real solid answer.

Robblee: Thank you. Thank you.

O’Brien: I think that’s a real solid answer. You said your answer wasn’t going to be perfect, but that’s pretty solid, right there.

Robblee: I don’t have anything to tell you that that’s for sure what happens, but that’s at least how I can theorize that it happens.

O’Brien: Understandable. And what we know about migraine and chronification of migraine, then it all makes sense. So I think that’s a good answer.

Robblee: Perfect. I tried to support it with everything I said before.

O’Brien: I love it. So we have another question we’ll get to, and then I know you have to run. Can people who have aura safely use hormones or do hormone replacement therapy?

Robblee: So really controversial question, and you’re going to see every single healthcare professional that you see is going to have a different level of comfort with that. But we do know that people who have migraine with aura have an increased risk of stroke compared to the general population. So that’s why we get worried about these hormones.

So we know that if you’re on a birth control pill, and you have migraine with aura, if you take 100,000 of those people, 35 to 40 are going to have a stroke. If you compare that to people who have migraine but no aura, and they’re on a birth control pill, that risk is about 25 per 100,000. So about 10 people different out of 100,000.

So there is absolutely a true increased risk, but what we call the absolute risk is very small. So I mean, out of 100,000 people, not even 1 in 100 are getting a stroke. So it’s still a very small likelihood of it happening, but that increased risk is real.

We know that risk is not related to progesterone. There’s absolutely no concern with progesterone when you have migraine with aura; it’s related to the estrogen component only.

Interestingly, we do know that there is an association between migraine aura and between estrogen. So for instance, while you don’t necessarily have a higher likelihood of having either type of migraine, the migraine with aura attacks are more commonly during different phases of your menstrual cycle, and it seems to be related to an increase in estrogen.

We can also see a change, or an increase, or a new occurrence of migraine aura during pregnancy or when you start a birth control pill. And then we can actually see a change around the perimenopausal time where I’ve seen it be that you lose the headache with your aura, you have new aura, just various things like that change. So around that sort of perimenopausal time, you can see all of those things change.

So getting back to the question. It seems like lower doses of estrogen are probably safer. And in fact, there’s even small studies that have looked at whether or not being on just a very low dose estrogen pill, where you’re then keeping your levels of estrogen more constant may be helpful.

And for some people, it is, and some people actually feel like their migraine and migraine with aura attacks are better when they’re also on hormonal therapy around the perimenopausal time. And in those cases, you’re really just supplementing back up to what your natural levels were before your estrogen started to drop off.

So it seems like fluctuations and big jumps in estrogen trigger that migraine and that migraine with aura. However, we also then know that there’s this associated increased risk of stroke.

A lot of those studies are older. They’re when our birth control pills had much higher doses. And so we feel like we need to do some newer, large studies to really show what the safety is with these low dose.

Some people will allow it, making sure you really understand the risks and that your reason for being on it, for you, provides enough benefit that you feel that that’s a worthwhile risk. But I know other people will just say, you know what, I really don’t think it’s safe, I don’t think you should be on it. So you’ll see people on different ends of the spectrum, depending on who you talk to.

If you are going to be on estrogen when you have aura, you want to make sure all your other risk factors are just minimized as much as possible. One in particular is making sure you don’t smoke because that’s going to really, really significantly increase your risk of stroke further if you already have aura and you’re on that estrogen.

So again, really complicated conversation. Something that’s important to have with your neurologist, your gynecologist, your PCP, whoever it is that’s helping you manage that. And like I said, you may get different opinions, depending on who you talk to. And some of these societies will recommend against it as well. So again, it’s a very controversial topic. And one, again, that has a lot of nuances, like everything we’ve talked about.

O’Brien: It’s all complicated and complex, but I really do think you helped us gain some perspective and insight. So I really appreciate you, Dr. Robblee. Thank you so much for joining us for this episode of Spotlight on Migraine.

Robblee: My pleasure. I had such a good time. Thanks so much for having me.

O’Brien: We’re so glad that you could join us. Always a pleasure talking to you as well.

And for all of you out there listening, watching, and following along, hopefully we answered some or all of your migraine with aura questions. We really appreciate you.

And for the Association of Migraine Disorders, I’m Molly O’Brien. That wraps up this episode of Spotlight on Migraine. See you next time.

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