What is the recommended treatment for migraine with aura?

Treatment of Migraine with Aura

For migraine with aura, first-line acute treatment is NSAIDs or aspirin started as early as possible during the aura phase, followed by triptans when the headache begins if NSAIDs are insufficient. 1

Acute Treatment

First-line Treatment

• Start NSAIDs (ibuprofen, naproxen, diclofenac) or aspirin as soon as possible during the aura phase
  • These medications won't treat the aura itself but can prevent or reduce the severity of the subsequent headache 1, 2
  • Acetaminophen alone is ineffective 1

Second-line Treatment

• If NSAIDs provide insufficient pain relief, add triptans when the headache phase begins 1
  • Triptans should not be used in patients with:
    • Uncontrolled hypertension
    • Basilar or hemiplegic migraine
    • History of stroke or TIA
    • Cardiovascular disease risk factors 1, 3

Administration Route Considerations

• Use non-oral routes of administration when nausea/vomiting is significant 1
• Consider antiemetics as adjunct treatment for nausea/vomiting 1

Preventive Treatment

Preventive treatment should be considered for patients with:

• ≥2 migraine attacks per month with disability lasting ≥3 days/month
• Use of acute medication more than twice per week
• Contraindication to or failure of acute treatments
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura) 1

First-line Preventive Medications

1. Beta-blockers:

   • Propranolol (80-160 mg daily)
   • Metoprolol (50-100 mg twice daily)
   • Atenolol (25-100 mg twice daily)
   • Timolol (20-30 mg daily) 1

2. Angiotensin II receptor blocker:

   • Candesartan (16-32 mg daily) 1

3. Anticonvulsant:

   • Topiramate (50-100 mg daily) 1
   • Note: While effective for migraine prevention generally, topiramate may not specifically prevent aura symptoms 4, 5

Second-line Preventive Medications

• Amitriptyline (10-100 mg at night) 1
• Flunarizine (5-10 mg daily) 1
• Sodium valproate (600-1,500 mg daily) - absolutely contraindicated in women of childbearing potential 1

Third-line Preventive Medications

• OnabotulinumtoxinA (155-195 units to 31-39 sites every 12 weeks) 1
• CGRP monoclonal antibodies:
  • Erenumab (70 or 140 mg subcutaneous once monthly)
  • Fremanezumab (225 mg subcutaneous once monthly or 675 mg quarterly)
  • Eptinezumab (100 or 300 mg intravenous quarterly) 1

Special Considerations for Migraine with Aura

1. Cardiovascular Risk:

   • Migraine with aura is associated with increased risk of ischemic stroke 1, 2
   • Combined hormonal contraceptives with estrogens are contraindicated in women with migraine with aura due to significantly increased stroke risk 1, 2

2. Differential Diagnosis:

   • Aura symptoms typically develop gradually (≥5 min), occur in succession, and are fully reversible
   • If symptoms have sudden onset, occur simultaneously, or correspond to a cerebrovascular territory, emergency evaluation for TIA is necessary 1, 2
   • Red flags requiring further investigation:
     • Aura duration >1 hour
     • Late onset of aura
     • Dramatic increase in aura attacks 2

3. Monitoring Treatment Response:

   • Use headache calendars to track frequency, severity, and duration of attacks
   • Evaluate effectiveness of treatment after 2-3 months 1
   • If treatment fails, review diagnosis, treatment strategy, dosing, and adherence before changing medications 1

Common Pitfalls to Avoid

1. Mistaking aura for TIA or stroke - aura symptoms typically develop gradually over ≥5 minutes and spread, while TIA symptoms have sudden onset 1

2. Using triptans during the aura phase - wait until headache begins 1, 2

3. Prescribing combined hormonal contraceptives to women with migraine with aura - significantly increases stroke risk 1, 2

4. Medication overuse - limit acute treatment to no more than twice a week to prevent medication overuse headache 1

5. Inadequate trial period for preventive medications - efficacy may not be observed immediately and should be evaluated after 2-3 months 1