Migraine aura: results from an art contest Aura da resultados de um concurso de arte

of drawings, paintings and digital art that expressed realistic results of a visual aura of migraine and answering of a questionnaire. The awards were separated in two categories (painting/drawing and digital art/photography) and amounted up to R$ 5,000. R esults : There were 139 participants, 24% men and 76% women. The most common visual aura’s characteristic was the presence of colorful points, and the less frequently was golden. The mean duration of visual aura was 110.6 minutes (450.5 of standard deviation), median of 20 minutes, minimum of 1 minute and maximum of 3600 minutes. 36.7% of the subscribers have only one kind of visual aura and 33.8% answered that have more than one kind. 46,5% said that their visual aura almost never occurs without pain after or while aura and 19% reported that their visual aura always occurs without a headache. Conclusion: Art contests are useful tools for disease awareness. Further actions in disseminating aura images may help migraine aura underdiagnosis and undertreatment.


INTRODUCTION
Migraine is a common primary headache and a major cause of disability 1 . It is characterized by recurrent episodes of headache often associated with nausea, vomiting, photophobia and phonophobia. The annual prevalence in general population is an average of 12%, and it is more frequent in 25 to 55 years old individuals and women population 2 . Patients have episodic attacks separated by interictal phases. The attack is an interplay between genetic 3 and environmental factors, possibly resulting in a dysfunctional state and structure alteration of the brain 4,5 .
In at least a third of migraine attacks, the headache is preceded and/or accompanied by reversible neurologic symptoms, named aura. This condition is classified as migraine with aura, a subtype of migraine disorder. In early descriptions, aura is linked to migraine since 1870, when Elliott showed the idea of migraine as a disorder characterized by aura, and associated with creativity, intellect, and visual disturbance.
According to Headache Classification Committee of the International Headache Society (IHS) 6 , aura is described as one or more of visual, sensitive, speech, motor, brainstem or retinal symptoms. Positive and/or negative visual manifestation is the most frequent phenotype, present in 98% of the patients 7 . Prevalent symptoms are flashes of bright light, foggy/blurred vision, zigzag or jagged lines, scotoma and phosphenes; and less frequent are more complex perception, such as misperception of distance, fractured vision, dysmorphopsias, tunnel vision, hemianopsia, curved or circular lines, among others 8 . Since visual auras varies in form, severity and duration both among patients and within each patient 9 , the anatomical location, extent and probably nature of the underlying occipital dysfunction must vary.
Migraine with aura are underdiagnosed and undertreated, partially because of misdiagnosis 10 . The consequences are chronic migraine, decreased quality of life and work productivity [11][12][13] . A detailed aura iconography is important for better recognition, prevention and treatment of migraine with aura.
An aura art contest was performed by ABRACES (Brazilian Association of Cluster Headaches and Migraines), so more images can be used for raising awareness of population and professionals, decreasing the gap between diagnosis and treatment.

METHODS
The Art Contest Migraine Visual Aura by ABRACES involved free subscription of drawings, paintings, digital art and photography that expressed realistic results of a visual aura of migraine. The applications were open to September 22th until October 6 th , 2019. The awards were separated in two categories (painting/drawing and digital art/photography) and were equivalent to up to R$ 5.000.
The participants were people that have migraine with visual aura or people with artistic skills that asked somebody who has.
Visual aura was characterized as a disturbance of visual perception that occurs before the start of a migraine (or during), in a gradual way, lasting five minutes to one hour and completely reversible. Some questions were ascertained, such as: "how did you hear about the contest?", "are you submitting this work to someone else?", "how long does your aura take on average (in minutes)?", "do you have more than one type of aura?", "does your visual aura occur without a headache?" and "what are the characteristics of your visual aura?".
Double data and data not properly filled were excluded to analyzing the results.

Statistical analysis
Categorical variables are presented as percentages and absolute number and continuous variables are presented as means with standard deviation, median, maximum and minimum data.

RESULTS
There were 139 participants in the contest. It was composed by 24% men and 76% women.
Most of participants heard about the contest by social medias: Instagram (38%) and Facebook (38%), 9% from google, 9% from ABRACES website, 5% from other vehicle of information and 1% from interview. The great majority submitted their own art expressing their visual aura. Figure 1 detailed the prevalence of the characteristics of the visual aura. The most common was presence of points and colorful and the less common was golden. 20% of the participants answered that their visual aura has others features not mentioned.
The mean duration of visual aura was 110.6 minutes (450.5 of standard deviation), median of 20 minutes, minimum of 1 minute and maximum of 3600 minutes.
About the predominance of the pattern of visual aura, 36.7% of the subscribers have only one kind of visual aura and 33.8% answered that have more than one kind. Besides visual aura, 6% of the participants also present loss of strength in one half of the body, 9% have difficulty of speaking and 14.4% show tingling of in a half of face or body (Figures 2 and 3).
About the relation with headache, 8 participants did not fill the field. From 131 of the participants that answered, 46.5% said that their visual aura almost never occurs without pain after or while aura and 19% reported that their visual aura always occurs without a headache (Figures 4, 5 and 6).

DISCUSSION
The visual aura contest attracted a significant number of participants who contributed with representations of migraine auras. This helped us in generating new iconography of migraine aura and therefore will be of help in increasing awareness of this underdiagnosed condition. Art contests are a useful tool for awareness campaigns. The images uploaded were from a great variety of visual auras.
Aura features reported by the participants were like the ones described in previous papers 8,14 .
Further spread of the images is planned, a book with aura images is under development and hopefully will published soon. The same images could be uploaded and disseminated via social media and website / search engine such as Google. Indeed Health information is one of the most frequently searched topics on the Internet 15 .
Availability of aura images to the general public may increase aura diagnosis, improving the access to migraine or other headache sufferers because recognition of visual patterns by patients is likely to occur.