What is the treatment for ophthalmologic migraines?

Treatment for Ophthalmologic Migraines

For ophthalmologic migraines, first-line treatment consists of NSAIDs such as aspirin, ibuprofen, or naproxen sodium, followed by triptans if NSAIDs are ineffective. 1

Acute Treatment Algorithm

First-Line Treatment

• NSAIDs:
  • Aspirin: 650-1000 mg every 4-6 hours (maximum 4g daily)
  • Ibuprofen: 400-800 mg every 6 hours (maximum 2.4g daily)
  • Naproxen sodium: 275-550 mg every 2-6 hours (maximum 1.5g daily)
  • Add an antiemetic if nausea is present

Second-Line Treatment (if NSAIDs fail after three consecutive attacks)

• Triptans:
  • Sumatriptan (oral, intranasal, or subcutaneous depending on severity and presence of nausea)
  • Rizatriptan
  • Zolmitriptan
  • Naratriptan

Third-Line Treatment (if triptans fail)

• Ditans or gepants (where available)
• Consider rescue medications such as opioids only when other treatments fail and risk of abuse is addressed 1

Route of Administration Considerations

• Use non-oral routes (intranasal, subcutaneous) when significant nausea or vomiting is present 1
• Sumatriptan subcutaneous injection is particularly useful for rapidly escalating attacks or when oral medications cannot be tolerated 1

Preventive Treatment

Consider preventive treatment if:

• Migraines occur ≥2 days per month with significant disability
• Acute treatments are ineffective or contraindicated
• Medication overuse is occurring (using acute treatments more than twice weekly)
• Uncommon migraine conditions are present 1

Preventive Medication Algorithm:

1. First-line preventives:

   • Beta-blockers (propranolol 80-240 mg/day, metoprolol, atenolol, or bisoprolol)
   • Topiramate (start low, typically 25 mg, and gradually increase)
   • Candesartan

2. Second-line preventives:

   • Amitriptyline (30-150 mg/day)
   • Flunarizine (where available)
   • Sodium valproate (in men only; contraindicated in women of childbearing potential)

3. Third-line preventives:

   • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab)

Important Clinical Considerations

Medication Overuse Risk

• Limit acute treatments to no more than twice weekly to prevent medication overuse headache 1
• Monitor for rebound headaches, particularly with opioids, triptans, and caffeine-containing medications

Triptan Safety Considerations

• Contraindicated in uncontrolled hypertension, coronary artery disease, and basilar or hemiplegic migraine 2, 3
• May cause vasospastic reactions, including coronary artery vasospasm
• Monitor for serotonin syndrome when combined with SSRIs or SNRIs

Non-Pharmacological Approaches

• Consider neuromodulatory devices, biobehavioral therapy, or acupuncture as adjuncts to medication or when medications are contraindicated 1
• Limited evidence supports physical therapy, dietary approaches, or supplements like magnesium and riboflavin

Special Considerations for Ophthalmologic Migraines

• Rule out secondary causes of visual symptoms, especially when presentation is atypical 4, 5
• Be aware that some preventive medications like topiramate can rarely cause ophthalmologic side effects, including acute angle-closure glaucoma 4
• For ophthalmoplegic migraine (now classified as a cranial neuropathy rather than migraine), steroids may be considered in addition to standard migraine treatments 5

By following this stepped approach to treatment and considering both acute and preventive strategies, most patients with ophthalmologic migraines can achieve significant improvement in symptoms and quality of life.