When does migraine aura occur?
Migraine aura is a visual disturbance that usually precedes the headache in about 20% of migraine sufferers. 
The aura can sometimes occur without a headache and some people, myself included, always have migraines and auras independently of each other. A typical aura usually lasts 20-30 minutes and consists of partial loss of vision on one side of both eyes, or flashing lights, colored zigzags, or tunnel vision. 
Most headache specialists and neurologists have always believed that most people have an aura first and when it resolves, the headache begins. A study by Dr. Jakob Hansen suggests that this may not be the case. He examined diaries of 201 adults who experienced 861 migraine attacks and discovered that in 61% of attacks the headache was present within 15 minutes of the onset of aura. Nausea was present in 40%, sensitivity to light (photophobia) in 84% and to noise (phonophobia) in 67% within 15 minutes of the onset of visual aura. I have heard from some of my patients similar reports of a headache and aura starting at the same time, but it seemed that those were a small minority. I will have to be more thorough in questioning my patients. One practical application of this finding is that we usually tell patients who use injectable sumatriptan (Imitrex) to treat their migraine attacks to wait for the aura to resolve and then take the injection. The reason for this delay is a perception that the injection will not help if taken during the aura phase. It is speculated that if the medicine gets into the brain circulation before pain starts it may not be able to attach itself to certain receptors. We do recommend taking a tablet as soon as the aura starts because it takes at least 30 minutes for a tablet to be absorbed. If Dr. Hansen’s results are confirmed, then most people should not wait to give themselves an injection of sumatriptan.
Since we are on the subject of injections, I should point out that they are extremely underutilized. Doctors usually prescribe them if the patient has severe nausea or vomiting and cannot hold down the pill. However, an injection may also be very useful for someone who wakes up with a headache without severe nausea, but they know that the tablet may take 2 hours or longer to provide relief. Taking an injection, which can stop the headache within 10 – 15 minutes, can make a difference between being able to go to work or not. I sometimes take an injection even when I have a mild migraine if it happens at night. The tablet will usually work, but I may have to wait for two hours before I can fall asleep, so I take a shot. From left to right 3 types of sumatriptan injectors: Alsuma, Sumavel, Imitrex injections. 
I am in the middle of an aura as i write this. I have never experienced a headache associated with the aura, nor any of the other symptoms mentioned. I have had them for about the last 25 years (at age 66) and can only regard them as a minor irritant- and, at that, only because they interfere with my ability to focus on visual details at times, especially during the initial onset, but this lessens with dissipation of the aura fairly quickly. I even experienced a prolonged aura in the middle of ….er, “relations”, while on a family vacation nestled with my wife in a cabin on Lake George in upstate NY on a beautiful autumn evening. Not a deal-killer, and we laughed about it afterward.
I did go through about a 5-year period of infrequent crippling migraines, which ceased about five years ago, concurrent with starting treatment for blood pressure issues. I had assumed that they were more connected to sinus problems.
To Isabel Smith: $8 a bottle is very expensive for sugar. Because that’s all anything “homeopathic” is, is sugar. It is all a sham, and you are experiencing placebo effect. Homeopathy is NOT science, and it has been thoroughly debunked as quackery by the entire science and medicine community. Go peddle your crap elsewhere.
I have the aura preceding the headache. However, as soon as I begin to experience the aura, I take a homeopathic remedy named ‘Phosphoricum Aciduum’ in pellet form, 30C potency. It is cheap, at a cost of around $8.00 per bottle, and it has enough pellets to last for dozens of uses. Works like a charm. Sometimes I need to repeat the dose of four pellets under the tongue, after half an hour or so, if the aura begins to appear again. I also take Bryonia homeopathic remedy, same 30C potency, 5 minutes or so after the Acidum Phos.
There are at least 4 different kinds of devices for injecting sumatriptan (Imitrex), so the best thing to do is to ask your pharmacist. Another option is to check the name of the manufacturer on the label and see if the manufacturer’s website has instructions.
I find it very difficult to use the Imitrex injectable. I use it on my belly but found it difficult use the BLUE mechanism. What am.I doing incorrectly?
The injectable is nice in order to have an ability to get something with such a rapid onset.
I looked into it once and my ins would not cover it (Sumavel) however I can attest to the frustration and pain of waiting 2+ hrs for a tradirional triptan to kick in while the HA gathers steam.
Thank you for the interesting blog entry on visual aura to headache transition. I really appreciate your personal account of your own experience with migraine.
Migraine with visual aura has a strong genetic component in my family and we all experience the headache phase before the aura ends. We also sometimes have numbness and weakness on one side of our body that progresses from our thumb to fingers, to hand, to arm, to face, to jaw and then tongue along with nausea and vomiting. We also experience difficulty speaking and considerable dizziness. Two of my 3 siblings and I have all transitioned into chronic migraine as we’ve aged. We have each experienced periods of chronic migraine throughout our lives but after 30+ years each living with migraine, the headaches in each of us have transitioned into chronic migraine (last 5 yrs now for me, age 40 -last 3 yrs for my brother, age 54 -and last 1-2 yrs for my sister, age 51). I am now 1.5 years into Botox treatment and do experience some relief, but my siblings do not receive Botox treatment.
One other thing you may with to consider asking your patients is whether they experience MULTIPLE visual aura phases. This is also common in my family. We sometimes experience visual aura, then the headache begins before the visual aura ends and then ~2 hours later we will experience ANOTHER visual aura at the same time as the headache continues (or it could be the remaining soreness from the headache) and then continued headache and this can repeat itself several times over the course of an 8-12 hour episode. Fortunately, this doesn’t always occur as these are truly horrible headaches when they occur… VERY painful and the nausea and vomiting that accompanies the multiple auras is quite severe.
Thank you for taking the time to read my entry and your helping people with migraine!