An aura is a brief, subjective neurological phenomenon that often precedes or marks the onset of a seizure or a classic migraine headache. It may manifest as a sensory, motor, cognitive, emotional, or autonomic experience and typically reflects the focal onset of abnormal electrical activity in the brain.

Though historically considered a prodrome or warning of a seizure, auras are now classified as the initial stage of the ictal event—a focal seizure with retained awareness. In the context of migraines, however, an aura remains a prodromal event triggered by transient cortical dysfunction, typically due to vasoconstriction.

Pathophysiology

• Seizure-related Aura: Arises from an irritable focus in the cerebral cortex. As the abnormal electrical activity spreads, the patient experiences specific symptoms depending on the area of origin. For example, a bitter taste aura may suggest a focus in the frontal lobe.

• Migraine-related Aura: Thought to be caused by transient cranial vasoconstriction or cortical spreading depression, resulting in focal neurologic symptoms. These symptoms often precede the headache by 10 to 30 minutes and may serve as a valuable diagnostic and therapeutic cue.

Clinical features of aura

The presentation of an aura can vary widely. Classification based on symptomatology includes:

1. Affective Auras

• Sudden, unexplained fear

• Paranoia

• Emotional surges

2. Cognitive Auras

• Déjà vu: Sensation of familiarity with unfamiliar events

• Jamais vu: Perceiving known environments as strange or unfamiliar

• Flashbacks of past events

• Altered time perception (“time standing still”)

3. Psychomotor Auras

• Involuntary, repetitive movements (automatisms), including:

  • Lip-smacking

  • Chewing or swallowing

  • Grimacing

  • Picking at clothes

  • Wandering or climbing motions

4. Psychosensory Auras

• Auditory: Buzzing, humming, or ringing in ears

• Gustatory: Bitter, acidic, or metallic taste

• Olfactory: Perception of foul or burning odors

• Tactile: Numbness, tingling, or crawling sensations

• Visual: Scintillations (flashing lights), zigzag lines, blind spots

• Vertigo: Sensation of spinning or imbalance

Aura in migraine

In classic migraine (migraine with aura), patients may initially report a vague premonition followed by visual disturbances—commonly scintillations or fortification spectra. As the aura progresses, it may lead to temporary visual field deficits. Sensory symptoms such as numbness of the lips, face, or hands, mild confusion, or dizziness may precede the onset of unilateral throbbing headache. Additional features include:

• Photophobia

• Nausea

• Vomiting

Recognizing the aura phase allows timely administration of abortive therapy, potentially preventing or attenuating the headache phase.

Aura in generalized tonic-clonic seizures

A generalized tonic-clonic seizure may begin with or without an aura. When present, the aura helps localize the seizure focus. The ictal phase includes:

• Sudden loss of consciousness

• Tonic phase: Muscle stiffening

• Clonic phase: Rhythmic jerking, hyperventilation

Seizures typically last 2 to 5 minutes and are followed by a postictal phase marked by confusion, fatigue, and amnesia. Memory of the aura may be impaired due to altered consciousness during and after the seizure.

Emergency interventions

• If aura progresses to a seizure:

  • Rapidly evaluate and prepare for airway support and protection

  • Monitor for life-threatening complications such as apnea, cyanosis, or status epilepticus

• If aura precedes migraine:

  • Place the patient in a dark, quiet environment

  • Administer abortive therapy such as triptans or NSAIDs

  • Consider antiemetics if nausea is present

History and physical examination

A thorough clinical history is essential. Key questions include:

• Description of aura phenomena

• Frequency and duration of seizures or headaches

• Identifiable triggers (e.g., light, sound, stress, caffeine)

• Use and effectiveness of medications

• Impact on quality of life

When examining pediatric patients, use simple, direct questions such as:

• “Do you see anything strange before the seizure?”

• “Do you taste something bad or smell something funny?”Also, observe nonverbal cues like eye rubbing, spitting, or unusual movements that may represent an aura.

Patient counseling and special considerations

• Education:

  • Teach patients to recognize their aura symptoms as early warning signs.

  • Encourage timely use of medications to prevent seizure escalation or migraine attacks.

  • Explain the neurological basis of aura to reduce fear and improve compliance.

• Monitoring and Documentation:

  • Recommend keeping a headache or seizure diary to identify patterns and evaluate treatment response.

  • Review and adjust medications regularly.

• Lifestyle modifications:

  • Stress reduction techniques

  • Regular sleep, hydration, and avoidance of known triggers

• Pediatric care:

  • Recognize that children may forget or struggle to articulate auras.

  • Provide supportive, age-appropriate education and communication.

Conclusion

Aura represents a significant clinical marker in both epilepsy and migraine. Its recognition can aid in early diagnosis, guide therapeutic intervention, and inform the localization of neurological dysfunction. Whether through visual flashes preceding a migraine or a bitter taste before a seizure, aura offers a glimpse into underlying cortical activity that warrants careful attention in both adult and pediatric populations.

References

1. Hellier, S. (2013). Hormonal contraception and headaches: What are the prescriber’s options? The Nurse Practitioner: The American Journal of Primary Health Care, 38(12), 32–37.

2. Pestka, E., & Nash, V. (2012). Decoding genetics: Genetic aspects of migraine headaches. Nursing 2014 Critical Care, 7(2), 16–18.