Neuro-ophthalmology and migraine: visual aura and its neural basis

Abstract

Background: Migraine, a chronic neurological condition often accompanied by visual aura, which affects 15–33% of migraineurs, often presents as transient visual disturbances such as scintillating scotoma and teichopsia. These symptoms arise primarily from cortical spreading depression (CSD) within the occipital cortex and significantly impacts the quality of life, with chronic and episodic migraineurs consistently scoring lower scores in vision-specific quality of life questionnaires. Therefore, this narrative review explores the pathophysiology pertaining to visual aura in migraines, focusing on the role of CSD while evaluating current diagnostic and therapeutic approaches employed. Methods: A narrative literature review was conducted using PubMed and ScienceDirect, focusing on studies published between 2000 and 2025. Search terms related to migraine, visual aura, and cortical spreading depression were used to identify relevant original research, reviews, and clinical studies addressing the pathophysiology, diagnosis, and treatment of migraine-related visual aura. Results: Findings indicate that CSD drove transient visual symptoms by triggering waves of neuronal depolarization and hypoperfusion in the visual cortex. Contemporaneous treatment modalities target the headache phase of migraine, with limited alternatives for aura-specific intervention. Conclusion: Advancement in neuroimaging and genetic research offer promising avenues for early diagnosis alongside focused therapeutics for migraine with aura. However, current treatment strategies remain largely focused on the headache phase, with limited efficacy for aura-specific symptoms. Future therapeutic approaches targeting cortical spreading depression may offer more precise interventions for managing visual aura in migraine. © 2025 Elsevier B.V., All rights reserved.