The swirling sky in Vincent van Gogh’s masterpiece Starry Night is said to depict his experience of migraines with an aura. 

But you’re forgiven if the only thing your migraines-with-light-show prompt you to create is a dent in your pillow as you wait for the agony to end.

More than nine million migraine sufferers in America report experiencing the bizarre, sometimes dazzling visual effects called an aura in the minutes leading up to the actual head pain. No two auras—or visual migraines—are exactly alike, but people describe seeing zigzagging lines, geometric shapes, kaleidoscopic colors, or a shimmery hole in their vision. 

“At its earliest stage, it begins as a gray spot, as if they’re looking through a glass or haze. The spot starts to enlarge and vibrate, possibly with a multicolored border, and then it eventually drifts away,” says Rudrani Banik, M.D.,a neuro-ophthalmologist at Mt. Sinai Medical Center in New York and a lifelong migraine sufferer (also known as a migraineur). 

The initial episode can be truly terrifying.

“The first time I had a migraine, I was a 23-year-old medical student, and I thought I was having a stroke,” admits Dr. Banik. 

Whether you’re relatively new to this phenomenon or, like Dr. Banik, have become accustomed to the stages of your migraines, there’s lots to learn and understand about migraines with aura. 

Here are a few of the top questions patients have about visual migraines, answered.

Q: Are visual migraines eye related? 
A: Sometimes. 

The aura may be caused by vasospasm, which is the narrowing and subsequent expansion of blood vessels feeding the brain. 

The change in flow is believed to set off the brain’s version of an electrical storm in the visual cortex, where images are processed. However, the precise cause and chronology are still being hotly debated among researchers and migraine experts. 

What is known is that serious illnesses, injuries, and conditions can cause similar sensory disruptions. Tumors, strokes, brain bleeds, blood vessel issues, or other abnormalities can all interfere with the brain’s visual cortex, so a first migraine with aura typically requires prompt medical attention.

Dr. Banik stresses that brain and eye problems are rare in migraine with aura. “But with any kind of visual symptom, I strongly urge people not to wait but to get it checked out immediately to rule out something more serious,” she says. 

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Q: Does a visual migraine require a trip to the ER? 
A: No. Start with your eye doctor. 

Dr. Banik suggests calling an eye-health specialist first. Eye doctors have the right equipment to measure the eye’s field of vision and to peek at the blood vessels, tissues, and nerves in the back of the eye to rule out something potentially more serious.

“If you call your primary doctor or even go to an emergency room,” she says, “you will likely be referred to an eye specialist anyway.”

Disconcerting as the aura phase is, the vision disturbance leaves no lasting damage. The image—usually the blind spot with its shimmering border—grows and travels through the visual field before drifting off, typically after about 20 to 60 minutes. 

For the record, Dr. Banik says it’s a smart idea to get checked out after your first migraine—even if you didn’t experience an aura. 

“An evaluation is essential to rule out brain or retinal involvement,” she says. 

Q: What if this isn’t my first migraine with aura? 
A: Still get checked out. 

Along with ruling out possible serious conditions, she says it’s important for your doctor and you to establish a baseline for your migraine symptoms and patterns. 

Your doctor will also put together a treatment and monitoring plan for you to follow. She asks her migraine patients to keep a headache diary.

“You don’t need to go running to the eye doctor every time you have a migraine,” says Dr. Banik. “Just track the incidents and triggers and note how you followed the prescribed treatment plan.” 

Unless there’s a dramatic change—maybe your once-a-week migraine is occurring every day and for a much longer duration—your doctor doesn’t need to know about every episode. 

Q: My coworker’s visual migraine sounds nothing like mine. What’s up? 
A: Just to confuse things, there’s no textbook aura pattern.

And many doctors use different terms to describe a particular attack. One practitioner’s visual migraine is another’s ophthalmic migraine. 

What’s important is that you and your doctor get on the same page about your particular visual symptoms and triggers. Knowing your triggers lets you and your doctor put together a plan to avoid or accommodate them.

Allergists, for example, can help pinpoint specific allergens that set your symptoms in motion. If light is a trigger for your headaches, an eye doctor may prescribe tinted glasses or contact lenses to cut down on the brightness. A new diet can eliminate trigger foods, and countless other changes in your daily routine such as caffeine intake, sleep, and stress management can help you control episodes.

Q: Is a visual migraine ever an emergency? 
A: Yes! 

There are rare variations of migraine with aura that have visual symptoms you should be aware of and report right away.

Retinal migraine: It blinds one eye for five to 15 minutes. (In contrast, visual auras impact both eyes.) “The vision may go black, white, or shimmer,” says Dr. Banik, “but it fully reverses.” Rarely, this type of migraine can lead to permanent vision loss.

Hemiplegic migraine: Characterized by weakness on one side of the face or body, visual distortions, and a “pins and needles” sensation, it can simulate partial paralysis—masquerading as a stroke.

Ophthalmoplegic headache: Not technically a migraine, this headache comes about when a series of blood vessel changes occur around a complex nerve that goes to the eye muscle. Along with migraine-like pain, ophthalmoplegic migraine causes double vision and a droopy eyelid and can sometimes even affect pupil size.

Anytime you experience a sudden loss of vision, it’s important that you call your eye or family doctor—or even head straight to the ER—right away, says Dr. Banik. 

“It’s an emergency situation that requires an immediate medical evaluation to rule out a clot, an eye stroke, or a brain stroke,” she says. 

Q: What treatments are available? 
A: They range from lifestyle changes to prescription medications. 

Once your doctor has confirmed that your pain and visual symptoms are, in fact, a migraine with aura, he or she will suggest a treatment plan that’s based on your personal health history and symptoms.

The first step is beginning a headache diary to identify your particular triggers—so you know what to try and avoid, says Julie Waight, F.N.P.–B.C., a nurse practitioner at Headache and Pain Management Associates, with locations in Brookfield and Stamford, Connecticut.

For milder episodes, over-the-counter aspirin, ibuprofen, acetaminophen, or migraine-specific drugs that combine known pain relievers with caffeine can be effective.

Other times prescription medicines are in order. Triptans (tryptamine-based drugs) can diminish inflammation when taken early in an attack, while beta-blockers (ß-adrenergic receptor antagonists) can help normalize headache-related blood flow imbalances.

Antiepileptics or antidepressants can yield good results in some patients. And Dr. Banik has seen circumstances where “blood pressure and antiseizure medications may be able to help.”

Last year, the first pharmaceuticals in 50 years designed to prevent migraines, called CGRP inhibitors (which block calcitonin gene-related peptide, implicated in headaches) were approved for use, to great fanfare.

Good self-care can also play a role in the frequency and severity of visual migraines. Daily exercise, meditation, and other stress-relieving practices make a real difference for some people. A good night’s rest is also important.

“Once we do a complete history and neurological exam, 99% of the time I can eliminate someone’s worst fears and talk about how to live with migraines and auras,” says Waight. 

While you may not be able to totally eliminate your occasional light shows, you may be able to transform a debilitating condition into a manageable part of everyday life. 

“The best advice I give patients with visual migraine is that it’s a chronic disease, just like asthma and diabetes,” says Waight. “It’s treatable with a combination of medications and healthy lifestyle.”