What is the appropriate management for a young patient with a history of migraines, not on birth control, who experienced a visual aura while microdosing and was treated with Ubrelvy (ubrogepant)?

From the Guidelines

The patient should discontinue microdosing substances immediately and continue using Ubrelvy for acute migraine attacks, while also considering preventive therapy if migraines occur frequently, as recommended by the latest guidelines 1. The visual aura experienced by the patient, described as "little rainbow worms," although lasting only a few seconds, warrants careful monitoring due to its potential implications on migraine management and the possibility of underlying neurological conditions. Given the patient's history of migraines and the occurrence of a visual aura, it is crucial to prioritize preventive measures to reduce the frequency and severity of migraines.

• The patient should maintain a headache diary to track the frequency, severity, and potential triggers of migraines, which can help in identifying patterns and making informed decisions about preventive therapy.
• Lifestyle modifications, including regular sleep patterns, stress management, consistent meals, adequate hydration, and avoiding known triggers, are essential in managing migraines.
• Since the patient is not on birth control, hormonal influences on migraines should be closely monitored, as hormonal fluctuations can affect migraine frequency and severity.
• The use of Ubrelvy (ubrogepant) at a dose of 50-100 mg at the onset of symptoms, with a maximum of 200 mg in 24 hours, is appropriate for acute treatment of migraines with aura, as per the latest clinical guidelines 1.
• If the patient experiences frequent migraines (more than 4 days per month), considering preventive therapy with medications such as beta blockers, topiramate, or candesartan as first-line options, or flunarizine, amitriptyline, or sodium valproate as second-line options, should be discussed, as outlined in recent recommendations 1.
• Neurological evaluation with possible brain imaging may be warranted if visual auras become more frequent, change in character, or are accompanied by other neurological symptoms, to rule out other underlying conditions.

From the FDA Drug Label

UBRELVY is a prescription medicine used for the acute treatment of migraine attacks with or without aura in adults.

The patient's use of Ubrelvy for acute treatment of migraine with aura is within the indicated use of the medication. However, it is essential to note that the patient is not on birth control and has a history of migraines, which may require additional consideration.

• The drug label does not provide specific guidance on the management of patients with a history of migraines and aura.
• The patient's experience of a visual aura while microdosing and the fact that it only lasted a few seconds does not directly relate to the use of Ubrelvy.
• The previous neurologist's concern and instruction to report any recurrence of the aura should be taken into account, and the patient should be advised to seek medical attention if the aura recurs or worsens.
• Close monitoring of the patient's condition and regular follow-up with their healthcare provider are necessary to ensure the safe and effective use of Ubrelvy 2.

From the Research

Migraine Management

• The patient's history of migraines and experience of a visual aura while microdosing requires careful consideration of prophylactic treatment options 3.
• The choice of prophylactic drugs depends on efficacy, co-morbidity, side effects, availability, and cost, with beta-blockers, flunarizine, topiramate, valproate, and amitriptyline being the drugs of first choice 3.

Visual Aura and Prophylaxis

• Topiramate has been studied for its efficacy in migraine aura prophylaxis, but results show it is not effective in preventing migraine aura 4.
• Other anti-epileptic drugs like valproate and gabapentin may have a role in the treatment of migraine with aura, but their use requires careful consideration of potential side effects, especially in women of childbearing potential 5.

Treatment of Visual Disturbances

• Visual disturbances in migraineurs, such as visual aura, can be challenging to classify and treat, and may require a practical approach to assign the correct diagnosis and choose a medication for treatment 6.
• Valproate therapy has been shown to modify cortical excitability state and may be effective in treating visual cortex excitability changes in migraine with aura patients 7.

Ubrelvy (Ubrogepant) Treatment

• The patient's treatment with Ubrelvy (ubrogepant) for the migraine attack is a separate consideration from prophylactic treatment, and its effectiveness in treating migraine with aura is not directly addressed in the provided studies 3, 4, 5, 6, 7.