What is the recommended treatment for migraines with aura?

From the Guidelines

The recommended treatment for migraines with aura includes both acute and preventive approaches, with triptans such as sumatriptan or rizatriptan being first-line medications for acute treatment, and beta-blockers, anticonvulsants, or CGRP monoclonal antibodies being options for preventive treatment. For acute treatment, triptans such as sumatriptan (50-100mg orally) or rizatriptan (10mg) are first-line medications, taken at the first sign of headache after the aura phase 1. NSAIDs like ibuprofen (400-600mg) or naproxen sodium (500-550mg) can also be effective. For those who cannot take triptans, gepants such as ubrogepant (50-100mg) or rimegepant (75mg) are newer alternatives.

Key Considerations

• Preventive treatment should be considered if migraines occur more than 4 times monthly or significantly impact quality of life.
• Options for preventive treatment include:
  • Beta-blockers (propranolol 80-240mg daily or metoprolol 100-200mg daily) 1
  • Anticonvulsants (topiramate 50-200mg daily) 1
  • CGRP monoclonal antibodies (monthly injections) 1

Lifestyle Modifications

• Regular sleep, meals, exercise, and stress management are important for reducing migraine frequency and severity.
• Identifying and avoiding personal triggers like certain foods, alcohol, or hormonal changes can also reduce attack frequency.

Treatment Goals

• Treatment works by addressing the neuroinflammation, cortical spreading depression, and vascular changes that occur during migraine attacks with aura.
• The goal of treatment is to reduce the frequency, severity, and impact of migraines on quality of life.

From the FDA Drug Label

Sumatriptan tablets, USP are indicated for the acute treatment of migraine with or without aura in adults. Rizatriptan benzoate tablets are indicated for the acute treatment of migraine with or without aura in adults and in pediatric patients 6 to 17 years old. Efficacy was unaffected by the presence of aura; by the gender, or age of the patient; or by concomitant use of common migraine prophylactic drugs (e.g., beta-blockers, calcium channel blockers, tricyclic antidepressants) or oral contraceptives.

The recommended treatment for migraines with aura is sumatriptan (PO) or rizatriptan (PO), as both are indicated for the acute treatment of migraine with or without aura in adults 2 3. Rizatriptan (PO) is also indicated for pediatric patients 6 to 17 years old 3 3.

• Key points:
  • Sumatriptan and rizatriptan are effective for acute treatment of migraines with aura.
  • Efficacy is unaffected by the presence of aura.
• Main treatment options:
  • Sumatriptan (PO)
  • Rizatriptan (PO)

From the Research

Treatment Options for Migraines with Aura

• The treatment of migraines with aura (MwA) involves various therapeutic options, including preventive medications and acute treatments 4.
• Non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin are recommended to be started as soon as possible during the aura phase to avoid or diminish the headache phase 5.
• In case of failure of NSAIDs or aspirin, triptans can be used when the headache begins 5.
• Prophylactic treatments for migraine with aura are similar to those used in migraine without aura, based on limited randomized clinical trials specifically dedicated to migraine with aura 5.

Preventive Treatments

• Anti-epileptic drugs, such as topiramate and valproate, are effective for the preventive treatment of migraine 6.
• Other medications like gabapentin or lamotrigine may have a role in the treatment of those with allodynia or frequent aura, respectively 6.
• Beta-blockers, calcium channel blockers, and 5-HT antagonists are also used for migraine prophylaxis 7.

Specific Considerations

• Lamotrigine may be effective in treating migraine with aura, although it is not recommended for general migraine prevention 8.
• Lamotrigine has a high potential for efficacy, a low-risk profile, and is well-tolerated, making it a promising option for treating attacks of migraine with aura 8.