VARSDiagnosis of Migraine Aura
Visual Symptom Characteristics
VARS Score
Select the visual symptom characteristics present to estimate the probability of migraine with aura.
Guidelines & Evidence
Verified
Last Review: 2026-07-17
When to Use
When to Use
To diagnose migraine with aura (MA) in patients presenting with reversible visual disturbances.
To differentiate visual migraine aura from other reversible visual phenomena, nonspecific photophobia, or non-migrainous visual snow.
As a rapid screening or self-administered questionnaire in headache clinics, primary care, or ophthalmology settings when a full semi-structured neurological interview is not feasible.
In research studies and drug trials for reproducible, evidence-weighted phenotypic classification of migraine aura.
As an operational adjunct to ICHD-3 diagnostic criteria for migraine with aura, reducing inter-rater variability.
As an outcome measure to track visual symptom burden over time, including in persistent aura without infarction (PAWOI).
Patient Population
Derived and validated in 427 adults from the Danish Headache Center population (recruited 1999–2002) presenting with either established migraine with aura or other reversible, non-aura visual disturbances. Since more than 99% of MA patients experience visual aura at least once, the authors restricted the scale to visual symptoms for simplicity and generalizability.
Adaptations for Special Populations
Adolescent and pediatric cohorts: some validation studies report that a lower cut-off (≥4) performs better than ≥5 in children/adolescents with migraine with aura.
Self-administered questionnaire version: in a prospective clinic-based study of 240 migraine patients (55 with MA, diagnosed per ICHD-3), a cut-off of ≥3 gave the best classification performance (83.3% correct classification; sensitivity 96.4%, specificity 79.5%), suggesting the optimal threshold may need adjustment when the tool is self-completed rather than interviewer-administered.
Translated and culturally adapted versions exist (e.g., Korean), preserving the original five-item structure and relative item weighting.
Limitations
Only assesses visual symptoms; it does not capture other aura types (sensory, aphasic/language, motor, brainstem) that can occur without visual aura.
Developed and validated against ICHD-2 criteria (2004); current practice uses ICHD-3 (2018), though the visual aura features scored by VARS remain essentially unchanged between editions.
The comparator group in the original study was patients with other reversible visual disturbances related to primary headache — performance may differ in populations where TIA or other vascular visual events are a major differential.
Not intended to replace a full neurological workup or exclude secondary/vascular causes when red flags are present (e.g., abrupt onset, age >50 at first aura, atypical or prolonged duration, focal deficits).
The optimal cut-off is not fixed: self-administered use and pediatric populations have each shown a different optimal threshold than the original interviewer-administered adult cut-off of 5.
How it Works
Derivation Method
The Danish Headache Center enrolled 427 participants (probands and relatives from a large migraine genetics/epidemiology program, interviewed 1999–2002) who were classified by a trained physician using a validated semi-structured interview as having migraine with aura (ICHD-2) or other reversible, non-aura visual disturbances. The cohort was split into a derivation sample (n=214: 160 with MA and 54 without) and an independent validation sample (n=213). Logistic regression on the derivation sample identified five visual characteristics independently associated with a diagnosis of MA, and each was assigned a weight approximating its regression coefficient relative to the smallest coefficient among the five.
Score Components (maximum 10 points)
01
Duration 5–60 minutes (3 points): The strongest independent predictor; reflects the typical time course of cortical spreading depression.
02
Develops gradually over ≥5 minutes (2 points): Captures the "spreading" march of migraine aura, distinguishing it from the abrupt onset typical of ischemic events.
03
Scotoma (2 points): A visual field defect commonly reported during migraine aura.
04
Zig-zag lines / fortification spectra (2 points): A positive visual phenomenon considered highly characteristic of migraine aura.
05
Unilateral / homonymous field involvement (1 point): Reflects the unilateral cortical (occipital) origin of the aura.
Diagnostic Interpretation
01
Derivation sample, cut-off ≥5: sensitivity 96% (153/160; 95% CI 92–99%), specificity 98% (53/54; 95% CI 95–100%).
02
Validation sample, cut-off ≥5: sensitivity 91% (95% CI 86–95%), specificity 96% (95% CI 91–100%) — the figures generally quoted for clinical use.
03
Alternative cut-offs (derivation sample): ≥4 → sensitivity 97% (155/160), specificity 91% (49/54); ≥6 → sensitivity 83% (133/160), specificity 100% (54/54). A cut-off of 5 offered the best balance of sensitivity and specificity in the original study.
04
Score below the chosen cut-off: visual symptoms are less likely to represent typical migraine aura; consider alternative diagnoses, other (non-visual) aura types, or a secondary cause if clinical suspicion warrants.
Clinical Pearls
VARS vs ICHD Criteria
ICHD-3 criteria remain the diagnostic reference standard for migraine with aura. VARS operationalizes the visual-aura component of those criteria by attaching empirically derived weights to specific, easily elicited symptom characteristics, producing a single continuous score rather than a checklist of qualitative features. This makes it faster to teach, apply consistently across examiners, and use as a quantitative outcome measure — while still correlating closely with an ICHD-based diagnosis at the validated cut-off.
Differentiating Migraine Aura from TIA/Ischemic Events
The two VARS items with the highest weight — a gradual march over ≥5 minutes and a total duration of 5–60 minutes — are also the features most useful for distinguishing migraine aura from transient ischemic attack, where visual symptoms typically begin abruptly and are usually shorter or, less commonly, longer than the typical aura window. VARS should not substitute for a vascular risk assessment in patients with atypical features (older age at first aura, vascular risk factors, or abrupt-onset negative visual symptoms without positive phenomena).
Tuning the Cut-off to the Clinical or Research Need
The threshold can be shifted depending on priorities: raising the cut-off to ≥6 pushes specificity toward 100% (useful for strict case ascertainment in genetic studies or clinical trials), while lowering it to ≥4 favors sensitivity (useful for screening). Reported optimal cut-offs also vary by administration method and population — interviewer-administered adults (≥5), self-administered questionnaires (≥3 in one validation study), and some pediatric/adolescent cohorts (≥4) — so the cut-off should be chosen to match how the tool is being deployed.
Use Beyond Initial Diagnosis
VARS has been used as an outcome measure to characterize and follow persistent visual aura without infarction (PAWOI), re-scoring visual disturbance patterns over the course of treatment.
Higher VARS scores in patients with non-aura visual disturbance have been associated with a stronger link to migraine chronification, suggesting the score may carry prognostic information beyond binary MA classification.
Next Steps
Actions To Take as a Clinician
01
1. Score ≥ cut-off (typically ≥5, interviewer-administered): Confirm the diagnosis against full ICHD-3 criteria, then counsel the patient on aura recognition, stereotypy of attacks, and red flags that should prompt re-evaluation (change in aura pattern, new focal deficits, onset after age 50).
02
2. Assess vascular risk before prescribing contraception or hormone therapy: migraine with aura is a WHO/CDC-recognized contraindication (UKMEC/US MEC Category 4) to combined hormonal contraceptives due to increased ischemic stroke risk, particularly in smokers; discuss progestin-only or non-hormonal alternatives.
03
3. Select acute therapy with the aura phase in mind: triptans and other vasoactive abortives are generally used once the headache phase begins rather than during the aura itself, and should be used cautiously (or avoided) in patients with hemiplegic or brainstem aura.
04
4. Consider preventive therapy if attacks are frequent or disabling (e.g., ≥4 headache days/month or significant aura burden): options include beta-blockers, candesartan, topiramate, or CGRP-pathway therapies (monoclonal antibodies or gepants), selected with attention to comorbidities and, in women of childbearing potential, teratogenicity.
05
5. Score below cut-off or atypical features (abrupt onset, duration outside 5–60 minutes, persistent or crescendo pattern, motor or brainstem symptoms): broaden the workup — consider neuroimaging, TIA/stroke evaluation, seizure workup, or ophthalmologic assessment — rather than anchoring on a migraine diagnosis.
06
6. For visual disturbances that persist beyond a typical attack (>1 hour, or lasting days–weeks), consider persistent visual aura without infarction (PAWOI) and re-apply VARS serially as an outcome measure to track response to prophylactic treatment (e.g., lamotrigine has been reported useful in case series).
Reassess. Don’t Anchor
VARS is a diagnostic aid, not a substitute for clinical judgment. A high score supports a migraine-aura diagnosis but does not exclude a coexisting secondary cause in a patient with new vascular risk factors, and a low score should not delay further work-up in a patient whose story is otherwise concerning for TIA, occipital seizure, or another structural cause.
The Evidence
Original Derivation and Validation
The Visual Aura Rating Scale (VARS) for migraine aura diagnosis.
Eriksen MK et al. • Cephalalgia.. 2005;25(10):801-810. PMID: 16162257. Derived in n=214 (160 MA, 54 non-aura) and validated in an independent n=213 sample drawn from 427 total participants. A cut-off score ≥5 gave 96% sensitivity/98% specificity in the derivation sample and 91% sensitivity/96% specificity in the validation sample.
View SourceSelf-Administered Version
Validity and reliability of the self-administered Visual Aura Rating Scale questionnaire for migraine with aura diagnosis: A prospective clinic-based study.
Kim BK et al. • Headache.. 2021;PMID: 34106459. In 240 migraine patients (55 with ICHD-3-diagnosed MA), a self-completed VARS with a cut-off of ≥3 gave the best classification accuracy (83.3%), sensitivity 96.4%, specificity 79.5% — a lower optimal threshold than the original interviewer-administered version.
View SourceUse as an Outcome Measure
The visual aura rating scale as an outcome predictor for persistent visual aura without infarction.
Wang YF et al. • Cephalalgia.. 2008;28(12):1298-1304. Applied VARS (score range 0–10) to characterize visual disturbance patterns in 29 patients with persistent visual aura without infarction (PAWOI) and track response to treatment.
View SourceUnderlying Diagnostic Framework
The International Classification of Headache Disorders, 3rd edition (ICHD-3).
Headache Classification Committee of the International Headache Society (IHS). • Cephalalgia.. 2018;38(1):1-211. Current reference classification for migraine with aura; VARS was originally derived and validated against its predecessor, ICHD-2 (2004), but the core visual aura features scored by VARS are retained in ICHD-3.
View SourceClick to Read
Last Comprehensive Review: 2026-07-17