Original Article

Migraine aura symptoms: Duration,

succession and temporal relationship
to headache

Cephalalgia
0(0) 19
! International Headache Society 2015
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DOI: 10.1177/0333102415593089
cep.sagepub.com

Michele Viana1, Mattias Linde2,3, Grazia Sances1,

Natascia Ghiotto1, Elena Guaschino1, Marta Allena1,
Salvatore Terrazzino4, Giuseppe Nappi1, Peter J Goadsby5 and
Cristina Tassorelli1,6
Abstract
Background: As there are no biological markers, a detailed description of symptoms, particularly temporal characteristics,
is crucial when diagnosing migraine aura. Hitherto these temporal aspects have not been studied in detail.
Methods: We conducted a prospective diary-aided study of the duration and the succession of aura symptoms and their
temporal relationship with headache.
Results: Fifty-four patients completed the study recording in a diary the characteristics of three consecutive auras
(n 162 auras). The median duration of visual, sensory and dysphasic symptoms were 30, 20 and 20 minutes, respectively. Visual symptoms lasted for more than one hour in 14% of auras (n 158), sensory symptoms in 21% of auras
(n 52), and dysphasic symptoms in 17% of auras (n 18). Twenty-six percent of patients had at least one aura out of
three with one symptom lasting for more than one hour. In aura with multiple symptoms the subsequent symptom,
second versus first one or third versus second, might either start simultaneously (34 and 18%), during (37 and 55%), with
the end (5 and 9%), or after (24 and 18%) the previous aura symptom. The headache phase started before the aura (9%),
simultaneously with the onset of aura (14%), during the aura (26%), simultaneously with the end of aura (15%) or after
the end of aura (36%).
Conclusion: We provide data to suggest that symptoms may last longer than one hour in a relevant proportion of auras or
migraine with aura patients, and that there is a high variability of scenarios in terms of time relationship among aura
symptoms and between aura and headache.
Keywords
Migraine with aura, duration, symptoms, headache, time, temporal features
Date received: 18 March 2015; revised: 27 April 2015; accepted: 22 May 2015

Introduction
Migraine is the third most common disorder in the
world (1), with 30% of patients having migraine with
aura (2). Over time aura has been evaluated with
animal models, and in clinical, neuroimaging, vascular,
and neurophysiological studies. In clinical studies many
aspects have been well investigated, although the
duration, the succession of symptoms, and their relation with headache have not been addressed in detail.
A detailed description of the symptoms, including their
temporal features, is crucial when diagnosing migraine
aura, as there are no biological markers. Indeed the differential diagnosis includes cerebrovascular disorders,

1
Headache Science Center, C. Mondino National Neurological Institute,
Italy
2
Department of Neuroscience, Norwegian University of Science and
Technology, Norway
3
Norwegian Advisory Unit on Headaches, St Olavs University Hospital,
Trondheim, Norway
4
Universita` del Piemonte Orientale A. Avogadro, Department of
Pharmaceutical Sciences, Italy
5
Headache Group NIHR-Wellcome Trust Clinical Research Facility,
Kings College London, UK
6
Department of Brain and Behavioural Sciences, University of Pavia, Italy

Corresponding author:
Michele Viana, Headache Science Center, C. Mondino National
Neurological Institute, Via Mondino 2, 27100 Pavia, Italy.
Email: michele.viana@ymail.com

2
epilepsy and other life-threatening neurological
conditions.
With respect to aura duration a recent systematic
review of the topic (3) did not nd any article exclusively focusing on the duration of the aura. The authors
found 10 articles that investigated migraine with aura
features, including the aura duration. Those studies
have dierent limitations such as the fact that most of
the studies are retrospective and some of the prospective studies did not use a diary completed during the
attacks, putting them at risk for recall bias.
Moreover, in some previous studies the diagnostic
criteria for migraine with aura were dated or not clearly
stated. The pooled analysis of data from the literature
on aura duration showed that visual symptoms lasting
for more than one hour occurred in 6%10% of
patients, sensory symptoms in 14%27% and dysphasic symptoms in 17%60%. Another study investigating the characteristics of migraine visual aura, including
duration, has been published recently (4). In that study
the design was retrospective, reporting that 6.6% of
patients had a visual aura longer than 60 minutes,
whereas 7.4% of patients did not remember the aura
duration.
With regard to the timing of succession between
aura and headache, this has been evaluated in one
prospective study on 44 auras (5) and two retrospective
studies on a larger number of auras (6,7). The succession of aura symptoms has been evaluated on nine
auras in one prospective study (5).
Here we investigated by using a prospective diaryaided approach the temporal characteristics of migraine
with aura including the duration and the succession of
aura symptoms and the temporal relationship between
aura and headache.

Methods
We recruited 176 consecutive patients aected by
migraine aura at the Headache Centers of Pavia and
Trondheim. The study received approval by the local
ethics committees (C. Mondino National Neurological
Institute, Pavia and REC-Central, Trondheim) and all
patients signed an informed consent form. Enrollment
started in October 2012 and ended in July 2014.
Inclusion criteria were: i) patients aected for at least
one year by migraine with aura fullling International
Classication of Headache Disorders, second edition
(ICHD-2) criteria (8) for 1.2.1 (G43.10) typical aura
with migraine headache,1.2.2 (G43.10), typical aura
with non-migraine headache, 1.2.3 (G43.104) typical
aura without headache, excluding point 3 of C criteria
(each individual aura symptom lasts 560 minutes)
and where only one of point C1 or C2 had to be veried
to full C criteria; ii) age between 16 and 65 years.

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Exclusion criteria were: i) hemiplegic migraine; ii)
brainstem aura; iii) pregnancy; iv) variation of the
characteristics of aura and/or headache in the last six
months; v) patients with >2 vascular risk factors; vi)
history of myocardial infarction and/or transitory
ischemic attack (TIA) and/or stroke and/or other
thrombophilic disturbances; vii) patients with episodes
that are not clearly dierentiated from other disturbances (TIA, seizures).
All the patients prospectively recorded the characteristics of three consecutive attacks in an ad hoc aura
diary documenting the exact time for debut and remission of each individual aura symptom and of the headache. The patient was asked to describe each aura
symptom to be sure of what was being experienced,
and the main characteristics of headache attacks. In
the evaluation of the succession of individual aura
symptoms where two symptoms started simultaneously,
we designated the rst completing symptom as the rst
symptom (FS).
We collected only the diaries of patients who recorded the characteristic of three consecutive auras in
their respective diaries.

Results
Patients
Of the 176 patients recruited, 54 completed the diaries
during three consecutive auras for a cumulative number
of 162 auras recorded. Of the remaining 122 patients,
27 dropped out and 95 did not complete three aura
attacks and were therefore not included in the analysis.
The 54 patients with three evaluable aura diaries
(46 from Pavia, eight from Trondheim) had the following characteristics: 83% were female (45/54), average
age was 40  14 (range: 1865), the average age of
onset of migraine with aura was 23  11 (range: 6
60), average annual frequency of migraine with aura
attacks was 23  27 (range: 2130). A total of 85%
(46/54) of these patients had migraine aura with headache in all three attacks, 9% (ve of 54) had attacks of
both migraine aura with and without headache, and
6% (three of 54) had exclusively migraine aura without
headache. Thirty-eight patients also had migraine without aura that started at an average age of 17  8 (range:
745) while nine patients suer also from tension-type
headache. Twenty-two percent of patients (12/54) had a
familial history of migraine with aura with rst- and
second-degree relatives being considered. Magnetic resonance imaging (MRI) of the brain was performed in
46 patients; 35 of those (76%) had normal MRI ndings, 11 patients (24%) presented with white-matter
changes and no other MRI abnormalities were found
in any other patient.

Viana et al.
Twenty patients out of 54 were treated with migraine
preventives during the study period: Three patients
were using beta-blockers (two atenolol, one propranolol), ve calcium antagonist (four unarizine, one
cinnarizine), four amitriptyline, seven antiepileptic
drugs (four topiramate, one valproate, two lamotrigine)
and one a combination of antiepileptic drugs and beta
blockers (topiramate and propranolol).

Auras
Out of 162 auras that were evaluated, visual symptoms
occurred in 158 (97%), sensory symptoms in 52 (32%),
and dysphasic symptoms in 18 (11%). The cumulative
number of aura symptoms recorded is therefore 229.
The distribution of the various aura symptoms is
shown in Figure 1. A total of 107 auras out of 162

Visual

Duration of aura symptoms

Visual. The median duration of 158 visual symptoms
was 30 minutes (min) (interquartile range (IQR)
24.2545 range 510,860 min). They fell in the following
ranges: 010 min (n 9; 6%), 1120 min (n 28; 18%),
2130 min (n 59; 37%), 3140 min (n 21; 13%), 41
50 min (n 6; 7%), 5160 min (n 8; 5%), >60 min
(n 22; 14%) (Figure 2).
Somatosensory. The median duration of 52 sensory symptoms was 20 min (IQR 1545, range
51440 min). They fell in the following ranges:
010 min (n 9; 17%), 1120 min (n 18; 35%),
2130 min (n 9; 17%), 3140 min (n 3; 6%), 41
50 min (n 0), 5160 min (n 2; 4%), >60 min
(n 11; 21%) (Figure 2).

64% (n=104)

23% (n=37)

(66%) had one symptom, 44 (27%) had two symptoms

and 11 (7%) had three symptoms.
In Table 1 the frequency of dierent combination of
aura symptoms with respect to the number of symptoms per aura and the order of appearance of each
symptom has been reported.
All the diary data relative to onset and end of each
symptom were complete except for a dysphasic symptom whose resolution was not noted as the patient fell
asleep. In that case the time of headache onset was
recorded as starting before the patient fell asleep.

2% (n=3)
Sensory

7% (n=11)

Dysphasic. The median duration of 18 dysphasic symptoms was 20 min (IQR 1050, range 5105 min). They
fell in the following ranges: 010 min (n 5; 27%), 11
20 min (n 4; 22%), 2130 min (n 2; 11%), 3140 min
(n 1; 6%), 4150 min (n 2; 11%), 5160 min (n 1;
6%), >60 min (n 3; 17%) (Figure 2).

<1% (n=1)
Dysphasic

4% (n=6)

0% (n=0)

The raw distribution of duration of each aura symptom is reported in Figure 3.

Figure 1. Venn diagram illustrating the distribution of the

various aura symptoms in 162 auras.

Table 1. Frequency of different combinations of aura symptoms with respect to the number of symptoms per aura and the order of
appearance of each symptom.
Auras with one
symptom (n 107)

Auras with two symptoms (n 44)

Auras with three symptoms (n 11)

Symptom

n (%)

First
symptom

Second
symptom

n (%)

First
symptom

Second
symptom

Third
symptom

n (%)

V
S
D

104 (97%)
3 (3%)
0

V
V
S
D

S
D
V
S

36
6
1
1

V
S
V

S
V
D

D
D
S

6 (55%)
2 (18%)
3 (27%)

V: visual; S: sensory; D: dysphasic.

(81%)
(13%)
(2%)
(2%)

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40
Visual symptoms

Number of cases (% per aura disturbance)

35

Sensory symptoms
Dysphasic symptoms

30
25
20
15
10
5
0

1_10

11_20

21_30

31_40
41_50
Duration (min)

51_60

>60

Figure 2. Distribution of duration aura symptoms subdivided in groups of a period of 10 min until the first hour. Visual symptoms
(n 158), sensory symptoms (n 52) and dysphasic symptoms (n 18). Twenty-two out of 158 visual symptoms (14%), 11 out of 52
sensory symptoms (21%) and three out of 18 dysphasic symptoms (17%) lasted for more than one hour.

420
Visual symptoms
Sensory symptoms
Dysphasic symptoms

Duration of each symptoms

360

300

240

180

120

60

20

40

60

80
Aura attacks

100

120

140

160

Figure 3. Distribution of duration of all aura symptoms. Note that six symptoms (four visual and two sensitive) are not reported as
a technical matter as they lasted for more than 420 minutes.

Viana et al.
Aura symptoms lasting longer than one hour. As shown in
Figure 2, visual symptoms lasted for more than one
hour in 22 out of 158 auras (14%), sensory symptoms
in 11 out of 52 (21%), dysphasic symptoms in three out
of 18 (17%). When considering the aura symptoms as a
whole (n 229), 36 symptoms lasted for longer than
one hour (15%). Their duration fell in the following
ranges: one to two hours (n 18), two to four hours
(n 7), four to eight hours (n 5), 824 hours (n 2),
>24 hours (n 4).
In 29 out of the 162 auras (18%) there was at least
one symptom longer than one hour. Out of these 29
auras, in 23 (79%) there was only one symptom lasting
for more than one hour, in ve auras (17%) there were
two symptoms each lasting for more than one hour
while in one aura (4%) there were three symptoms
each lasting for more than one hour.
Out of the 29 auras with at least one symptom lasting for more than one hour, 12 were auras with one
symptom, 12 auras with two symptoms and ve were
aura with three symptoms.
Fourteen patients out of 54 (26%) experienced at
least one aura symptom lasting for more than one
hour in at least one of the three attacks. Of these
14 patients, six had all three auras with at least one
symptom lasting for more than one hour, while eight
(14% of the total 54 patients) experienced the same
aura symptoms lasting for more than one hour in one
attack and for less than one hour in another attack out
of the three.
We performed an analysis to evaluate if there was
any demographic or clinical variable associated with
having suered at least one prolonged aura, an
aura with at least one symptom lasting for more than

60 min, out of three attacks (n 14 of 54 patients).

We included age, gender, presence of headache associated with aura, frequency of migraine with aura
attacks, age of migraine with aura onset, duration of
illness, co-occurrence of migraine without aura or tension-type headache, age of migraine without aura
onset, use of migraine-preventive therapy, familial history of migraine with aura and white-matter lesions on
MRI in the analysis. In univariate analyses, none of the
clinical parameters was signicantly associated with the
fact of having experienced a prolonged aura
(Supplementary Table 1).

Succession of aura symptoms

Auras with at least two symptoms. In 55 out of 162 auras
(34%) there were at least two symptoms (44 auras with
two symptoms and 11 auras with three symptoms):
In 19 auras (34%) the second symptom (SS) started
simultaneously with the rst symptom (FS) (scenario
1 Figure 4); in 20 auras (37%) the SS started during
the FS (scenario 2 Figure 4); in three auras (5%) the SS
started when the FS stopped (scenario 3 Figure 4), in
13 auras (24%) the SS started after a free interval of
time (median duration 15 min, IQR 530 min) after the
end of FS (scenario 4 Figure 4). Data relative to the
interval between onset of FS and onset of SS are:
median 10 min, IQR 030 min (mean 21 min, SD
26 min, range 0120 min). The frequencies of dierent
symptoms with respect to their order of appearance are
reported in Table 1.
Auras with three symptoms. In 11 auras there were three
symptoms: In two auras (18%) the third symptom (TS)

Aura symptom A

Aura symptom B - scenario 1

Aura symptom B - scenario 2

Aura symptom B - scenario 3

Aura symptom B - scenario 4

Figure 4. Different scenarios of time relationship between aura symptom B in relationship to aura symptom A. Scenario 1: B starts
simultaneously with A; scenario 2: B starts during A; scenario 3: B starts when A stopped; scenario 4: B starts after a free interval of
time after the end of A.

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Aura

Headache - scenario 1

Headache - scenario 2

Headache - scenario 3

Headache - scenario 4

Headache - scenario 5

Figure 5. Different scenarios of time relationship between headache in relationship to aura. Scenario 1: headache started before
aura; scenario 2: headache started simultaneously with aura; scenario 3: headache started during aura; scenario 4: headache started
when aura stopped; and scenario 5: headache started after a free interval of time after the end of aura.

Table 2. Data related to intervals between aura onset/end and headache onset in different scenarios.
Interval between
Scenario 1
Scenario 2,3,4,5
Scenario 5

Onset of headache
Onset of aura
End of aura

Onset of Aura
Onset of headache
Onset of headache

Median (min)

Mean (min)

SD (min)

Range (min)

140
35
25

275
51
27

417
60
35

301440
0450
5215

Scenario 1: headache started before aura; scenario 2: headache started simultaneously with aura; scenario 3: headache started during aura; scenario 4:
headache started when aura stopped; scenario 5: headache started after a free interval of time after the end of aura (see also Figure 5). Min: minutes.

started simultaneously with the SS (scenario 1

Figure 4); in six auras (55%) the TS started during
the SS (scenario 2 Figure 4); in one aura (9%) the TS
started when the SS stopped (scenario 3 Figure 4). In
two auras (18%) the TS started after a free interval of
time (median duration 70 min, IQR 5090) after the end
of SS (scenario 4 Figure 4). Data relative to the interval
between onset of SS and onset of TS are the following:
median 25 min, IQR 8, 7535 min (mean 34 min, SD
39 min, range 0130 min). The frequencies of dierent
symptoms with respect to their order of appearance are
reported in Table 1.

The succession of aura and headache

In 15 auras (9%) out of the total 162, headache was not
present and in 31 auras headache was present but we do
not have any information about its onset. Of the
remaining 116 auras, in 10 (9%) headache started
before aura (scenario 1 Figure 5); in 16 (14%) headache
started simultaneously with aura (scenario 2 Figure 5);
in 30 (26%) headache started during aura (scenario 3

Figure 5), in 18 (15%) headache started when aura

stopped (scenario 4 Figure 5), and in 42 (36%) headache started after a free interval of time after the end of
aura (scenario 5 Figure 5).
Data related to intervals between aura onset/end and
headache onset in dierent scenarios are reported in
Table 2. With respect to scenario 5, only in two cases
out of 42 did the headache start after a free interval of
more than 60 minutes (65 and 215 minutes).
Intra-patient variability. Of the 54 patients who completed
the study, 35 patients experienced all three episodes of
auras associated with headache, while others had at
least one episode in which aura was not associated
with headache (n 6) or where we do not have any
information about headache onset (n 13). Of these
35 patients, 15 (43%) had the same scenario for
the three aurasin particular nine out of the 10 attacks
with scenario 1 fell into this group. Twenty patients out
of 35 (57%) presented with at least two dierent scenarios. In this latter group of patients, the dierences
between scenarios out of three auras were minor.

Viana et al.
In fact the dierence between the higher and lower
number of the scenario (see Figure 5) presented for
each patient was one in 13 patients (i.e. 2, 2, 1 or 4,
4, 3), two in six patients (i.e. 2, 4, 2 or 2, 2, 4) and three
in one patient (1, 3, 4).

Discussion
This prospective, diary-based study of aura demonstrates two important clinical-pathophysiological ndings. First, aura commonly, in about 20% of patients,
lasts longer than an hour in visual, somatosensory and
dysphasic presentations. Secondly, about one-third of
patients with aura have two or more distinct brain areas
involved. Lastly, in only one-half of patients is there the
textbook progression of aura followed by headache.
The data suggest, at the least, reconsideration of aura
terminology as the ICHD is being revised to include the
substantial group with longer aura duration. Moreover,
aura pathophysiology and its relationship to headache
need to be re-thought if current models fail to predict
the clinical data in half of cases.
The distribution of aura symptom duration was not
normal. Most of the symptoms lasted for 2030 min as
the median shows; indeed they can be longer than one
hour in a signicant proportion of auras (18%) and of
patients (26%). These data are in line with the results of
the systematic review on aura duration (3) although
here we did not nd relevant dierences in terms of
aura duration between the three aura symptoms.
In the ICHD third edition beta (ICHD-3 beta) (9)
migraine with typical aura 1.2.1, it is stated that
each individual aura symptom lasts 560 minutes.
Our data oer two options. First, does the one-hour
limit need review? Secondly, and as an alternative,
should the nosological entity dened as migraine
with prolonged aura included in ICHD-1 (10) and
dropped in ICHD-2 (8), be reintroduced in ICHD-3?
With respect to the time limit of symptoms duration,
we note our data show that 95% of aura symptoms
(218 out 229) last between ve min and four hours,
while just 5% of symptoms (11 out of 229) lasted for
more than four hours (ve between four and eight
hours, two between eight and 24 hours, four >24
hours). Indeed, for the rst time we have provided consistent data that show that aura symptoms can last for
more than one hour in a substantial proportion of
migraine patients and migraine auras. We favor the
one-hour rule as it does cover 80% of aura, and
would have no eect on data from the last 25 years.
Clinically, the result that migraine aura symptoms not
infrequently exceed the one-hour limit should be disseminated widely to avoid unnecessary investigations.
We evaluated a succession of individual aura symptoms in 55 auras with at least two symptoms and 11

7
auras with three symptoms. We noted that the subsequent aura symptoms might either start simultaneously,
during, with the end, or after, the previous aura symptom (see four scenarios in Figure 4). Only one previous
prospective diary-based study (5) reported data on this
issue, describing the time relationship of two symptoms
in nine auras. They fell in scenario 2 (ve out of nine)
and in scenario 4 (four out of nine). In ICHD-3 beta it
is stated aura symptoms of these dierent types usually follow one another in succession. We propose a
change to aura symptoms usually follow one another
in succession, the second one starting during, with the
end, or after, the previous aura symptom, although
they can also start simultaneously. We also noted
that aura symptoms might occur in dierent order,
and not just visualsensory and dysphasic. This concept is reported in ICHD-3 beta although in the literature no studies reported data on this aspect.
Regarding the temporal relationship between headache and aura, we found that the headache phase of
migraine with aura may either start before, simultaneously with the onset, during the aura, simultaneously
with the end, or after the end of aura. Our data are in
line with the those of a previous prospective study in
which a dierent diary/questionnaire was used on a
smaller number of auras (5) and two retrospective studies on a larger number of auras (6,7), although in
those studies it is not possible to deduce the frequency
of scenarios where the headache phase of migraine
either started during the aura, simultaneously with the
end of aura or after the end of aura (see Table 3). In the
literature we also found one prospective study that,
among other data, inquired generally about the presence of headache during the aura phase (11). Patients
were asked to record headache symptoms as soon as
possible after aura began and always within one hour
of aura onset. The study was not designed to dissect the
aura/headache relationship and does not provide any
specic clues in this regard. Our nding of no one rule
to link aura and headache suggests the pathophysiological explanation that cortical spreading depression
initiates pain needs revision in a substantial proportion
of cases.
Our data prospectively veried criteria C4 of
migraine with aura of ICHD-3 beta (9), the aura is
accompanied, or followed within 60 minutes, by headache in 96% of cases in which headache started after a
free interval of time after the end of aura. In ICHD-3
beta it is not noted that headache may start simultaneously or before aura onset, although this was documented in a signicant proportion of auras (up to
21%), as shown by this study and the three previous
ones reported in Table 3. Our study shows that patients
usually present with the same or similar scenario(s) of
succession of aura and headache during dierent auras.

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Table 3. Frequency of the five different scenarios of time relationship between headache in relationship to the aura, in the studies
available in literature and in the current one.
Study

Current study

Eriksen et al. (7) 2004

Russell and Olesen (8) 1996

Russell et al. (3) 1994

Design

Prospective
with diarya

Retrospective
(interview by MD)

Retrospective
(interview by MD)

Prospective with
diary/questionnaireb

# of auras
Scenario 1
Scenario 2
Scenario 3
Scenario 4
Scenario 5

116
9%
14%
26%
15%
36%

341
3%
5%

163
8%
11%

44c
11%
4%

82%*

91%*

85%*

Scenario 1: headache started before aura; scenario 2: headache started simultaneously with aura; scenario 3: headache started during aura; scenario 4:
headache started when aura stopped; scenario 5: headache started after a free interval of time after the end of aura (see also Figure 5).
a
Patients recorded time of onset/end of aura and headache during their occurrence.
b
The patients had to answer a question about the time relationship between onset of headache and aura (before, during and after) and to quantify the
duration before/after.
c
Auras were 54 but in some auras data were not complete.
*This value refers to scenarios 3, 4 and 5 together.

These data are particularly interesting if we consider

that almost all the patients (75%) who have experienced scenario 1headache starts before aura
retained the same scenario for all three auras.
The main limitation of this study is that patients
were recruited from tertiary referral centers. One
could then argue that in such a setting more dicult
cases are seen or unusual aura is referred for evaluation. This would account for the longer or more complicated aura presentations. We cannot, therefore, be
clear what the population proportion of these aura phenomena are with these data. This does not negate the
observations accuracy, since all patients were reviewed
by experts who re-took the history of secondary and
aura-like presentations. Practically speaking the use of
a detailed aura diary in a population-based study has
its challenges, and population-based studies always
have the issue of how detailed one can make the clinical

evaluation. Despite selection bias, the overall pathophysiological message must remain one of caution
since undoubtedly aura length, succession and relationship to headache are not one simple linear, timerestricted set of phenomena.
In conclusion, we performed the rst study specifically designed to evaluate temporal aspects of
migraine aura. It provides consistent results that
give wider insight into aura phenomenology such as
the fact that aura symptoms may be longer than one
hour in a signicant proportion of auras or migraine
with aura patients, and into the high variability of
the temporal relationship between aura symptoms
and between the onset of aura and headache. We
are condent that these data can provide reliable support in the clinical setting, the classication process,
as well as the pathophysiological research in migraine
with aura.

Clinical implications
. Unless very important, aspects hitherto of temporal features of migraine with aura have not been studied in
detail.
. Here we present data from an extensive, careful analysis of aura in a well-characterized clinical cohort.
. We provide data on duration that suggest aura is often longer than currently thought, careful documentation of succession of aura in patients with more than one manifestation, and new data on the relationship
with headache that has been debated much from bench studies.
. Our data will press for improvements to the International Classication of Headache Disorders and oer
new avenues for bench work as well as provide reassurance in clinical settings that seem more common than
has been considered.

Viana et al.
Acknowledgments
This study was carried out in collaboration with the
University Consortium for Adaptive Disorders and Head
Pain (UCADH), University of Pavia, Italy.

Funding
This work was supported by grants from the Italian Ministry
of Health to RC 20132015.

Conflict of interest
MV, ML, GS, NG, EG, MA, ST, GN, CT have nothing to
declare. PJG reports grants and personal fees from Allergan,
grants and personal fees from eNeura, personal fees from
Autonomic Technologies Inc, grants and personal fees from
Amgen, personal fees from Bristol-Myers Squibb, personal
fees from AlderBio, personal fees from Pzer, personal fees
from Impax, personal fees from Dr Reddy, personal fees from
Zosano, personal fees from Colucid, personal fees from Eli
Lilly, personal fees from Medtronic, personal fees from
Avanir, personal fees from Gore, personal fees
from Heptares, personal fees from Nupathe, personal fees
from Teva, personal fees from MedicoLegal work in headache, personal fees from Journal Watch, and personal fees
from UpToDate, outside the submitted work.

References
1. Vos T, Flaxman AD, Naghavi M, et al. Years lived with
disability (YLDs) for 1160 sequelae of 289 diseases and
injuries 19902010: A systematic analysis for the Global
Burden of Disease Study 2010. Lancet 2012; 380:
21632196.

9
2. Rasmussen BK and Olesen J. Migraine with aura and
migraine without aura: An epidemiological study.
Cephalalgia 1992; 12: 221228.
3. Viana M, Sprenger T, Andelova M, et al. The typical
duration of migraine aura: A systematic review.
Cephalalgia 2013; 33: 483490.
4. Queiroz LP, Friedman DI, Rapoport AM, et al. Characteristics of migraine visual aura in Southern Brazil and
Northern USA. Cephalalgia 2011; 31: 16521658.
5. Russell MB, Iversen HK and Olesen J. Improved description of the migraine aura by a diagnostic aura diary.
Cephalalgia 1994; 14: 107117.
6. Eriksen MK, Thomsen LL, Andersen I, et al. Clinical
characteristics of 362 patients with familial migraine
with aura. Cephalalgia 2004; 24: 564575.
7. Russell MB and Olesen J. A nosographic analysis of the
migraine aura in a general population. Brain 1996; 119:
355361.
8. Headache
Classification
Subcommittee
of
the
International Headache Society. The International
Classification of Headache Disorders (2nd edn).
Cephalalgia 2004; 24 (Suppl 1): 1160.
9. Headache Classification Committee of the International
Headache Society. The International Classification of
Headache Disorders, 3rd edition (beta version).
Cephalalgia 2013; 33: 629808.
10. Headache Classification Committee of The International
Headache Society. Classification and diagnostic criteria
for headache disorders, cranial neuralgias and facial pain.
Cephalalgia 1988; 8(Suppl 7): 196.
11. Hansen JM, Lipton RB, Dodick DW, et al. Migraine
headache is present in the aura phase. Neurology 2012;
79: 20442049.