Aura in Cluster Headache: A Cross-Sectional Study

Ilse F. de Coo, MD; Leopoldine A. Wilbrink, MD; Gaby D. Ie, MD; Joost Haan, MD, PhD; Michel D. Ferrari, MD, PhD


Headache. 2018;58(8):1203-1210. 

In This Article


We assessed the presence of aura in 629 participants with cluster headache and compared the clinical attack characteristics of cluster headache participants with typical aura with those without aura. Typical aura was found in 7.0% of participants, which lies within the range of other studies, in which aura prevalence varied from 0 to 23%.[2,13,18–22]

Consistent with the findings from previous studies,[3,4,13] the most frequent aura symptoms were visual, which in our study started in most cases prior to the headache. Dysarthria and dysphasia, most often during the headache phase, was reported by 27.3% and 22.7% participants, respectively, which seems much higher than the 4.5%–8% reported in previous studies.[2,4,5,13]

We and others[5] found no significant gender differences between participants with cluster headache with or those without aura. This is in contrast with migraine, as males proportionally have more often migraine with aura than females.[6,23] We found no difference in migraine comorbidity between cluster headache participants with and without typical aura.

In migraine with aura, the headache often lasts shorter and is less severe compared with those without aura.[6] We failed to find similar differences in attack characteristics between cluster headache with and without aura, except for more frontal pain and lower alcohol consumption in the former. The finding of a lower alcohol consumption in patients with aura is comparable with the situation in migraine, in which also a lower alcohol consumption was found in patients with aura.[24] Whether this implies that attacks with aura are more readily provoked by alcohol than attacks without aura remains a matter of speculation.

In participants with cluster headache with aura, we found a lower proportion of visual aura symptoms compared with aura studies in migraine. In migraine, visual symptom, sometimes combined with other aura symptoms, are reported in up to 99% of the migraine with aura patients.[25,26] A lower proportion of visual symptoms compared to migraine was reported in cluster headache in earlier studies.[3,27] Moreover, those who experienced aura associated with their cluster headache attack, and were known with migraine as well, did not always experience an aura during their migraine attack. Bahra reported that as well: those with aura symptoms associated with their cluster headache did not have aura with their migraine headache in 60% of their cases.[3]

The strength of this study is the large sample size, a well-defined cohort, an overall high response rate of 83.2%, and detailed information on cluster headache characteristics. Limitations include the retrospectively collected aura data. The major limitation is that we expect that we have missed patients with aura symptoms by using this questionnaire[17] and are uncertain about the amount of missed patients. We may have missed differences in population characteristics. It is a challenge to attempt to answer questions regarding aura via a questionnaire. Our interviews by phone confirmed that diagnosing typical versus atypical aura by only using a questionnaire is insufficient and has a low predictive value. Therefore, we would strongly advise for future researchers to diagnose aura by face-to-face or telephone interview (or a sample).

Further research should focus on several questions: (i) whether there are regional differences in aura prevalence related to cluster headache around the world, (ii) whether those with aura respond differently to standard treatment, (iii) if there are pathophysiological differences between those with and without aura, and (iv) whether there is a cortical spreading depression in cluster headache as underlying mechanism of the aura symptoms.

Physicians should be aware that cluster headache seldomly can be preceded or accompanied by aura symptoms. In our opinion, there is no need to add a separate diagnosis of cluster headache with aura to the ICHD-III criteria or include aura in the list of cluster headache symptoms according to the ICHD-III criteria. When occurring, typical aura symptoms related to cluster headache can be classified as typical aura with headache as before.[1]