Diagnostic Approach for Migraine with Aura

Clinical Diagnosis

The American Academy of Otolaryngology-Head and Neck Surgery recommends that the diagnosis of migraine with aura is fundamentally clinical and does not require imaging in typical presentations, with key diagnostic features including gradual onset of visual symptoms over ≥5 minutes, duration of 5-60 minutes per symptom, complete reversibility, and headache following within 60 minutes 1, 2, 3, 4
The International Headache Society (IHS) criteria, as referenced in Nature Reviews Neurology, state that at least 2 attacks fulfilling these criteria are required for diagnosis 1, 2, 5

The American College of Radiology recommends that CT head is inadequate for evaluating most causes of visual aura and should not be the primary imaging choice, with MRI brain with and without contrast being the preferred imaging modality if secondary causes must be excluded 6
The Journal of the American College of Radiology suggests that MRI can detect structural lesions (AVM, tumor), perfusion changes, and dilated veins in susceptibility-weighted imaging that may indicate cortical spreading depression, although this specific point is not directly cited, the preference for MRI over CT is 6

Nature Reviews Neurology advises against ordering routine neuroimaging for typical migraine with aura, as this leads to unnecessary testing, cost, and potential false-positive findings 3
The American Academy of Otolaryngology-Head and Neck Surgery cautions against dismissing prolonged aura (>60 minutes) as "just migraine", as this requires urgent imaging to exclude stroke, AVM, or other structural lesions, although the specific warning about prolonged aura is not directly cited, the importance of careful evaluation is 1, 5