What is the treatment for ocular migraines?

Treatment of Ocular Migraines

For ocular migraines, first-line treatment includes NSAIDs such as aspirin, ibuprofen, or naproxen sodium, while triptans should be used for moderate to severe attacks that don't respond to NSAIDs. 1

Understanding Ocular Migraines

Ocular migraine (also called retinal or ophthalmic migraine) is characterized by transient monocular visual disturbances that may include scintillations, scotomas, or temporary blindness, often followed by migraine headache 2, 3. These visual symptoms are fully reversible and may be triggered by visual stimuli such as striped patterns or flickering lights 4.

Treatment Algorithm

Acute Treatment

1. First-line medications 1:

   • NSAIDs:
     • Aspirin (650-1000 mg)
     • Ibuprofen (400-800 mg)
     • Naproxen sodium (275-550 mg)
   • Add antiemetic if nausea/vomiting is present

2. Second-line medications (for moderate-severe attacks or when NSAIDs fail) 1:

   • Triptans:
     • Sumatriptan
     • Rizatriptan
     • Zolmitriptan
     • Naratriptan
   • Important: Triptans are contraindicated in patients with cardiovascular disease or multiple cardiovascular risk factors 5

3. For attacks with significant nausea/vomiting 1:

   • Use non-oral routes of administration
   • Add antiemetics like metoclopramide or prochlorperazine

4. Rescue medications (for severe attacks unresponsive to above) 1:

   • Limited use of opioids may be considered when other treatments fail
   • Monitor carefully for medication overuse headache

Preventive Treatment

Consider preventive therapy when 1:

• Attacks occur ≥2 times per month with significant disability
• Acute treatments fail or are contraindicated
• Medication overuse occurs (using acute treatments >2 times/week)

Preventive medication options 1:

1. First-line preventives:

   • Beta-blockers without intrinsic sympathomimetic activity (metoprolol, propranolol)
   • Topiramate
   • Candesartan

2. Second-line preventives:

   • Amitriptyline
   • Flunarizine (where available)

3. Third-line preventives:

   • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab)

Non-Pharmacological Approaches

• Identify and avoid visual triggers (flickering lights, striped patterns) 4
• Implement lifestyle modifications 1:
  • Regular sleep schedule
  • Regular meals and adequate hydration
  • Stress management techniques
  • Exercise program
• Consider biofeedback, cognitive-behavioral therapy, or acupuncture 1

Important Considerations

• Take medications early in the attack when pain is still mild 1
• Limit acute medication use to ≤2 days/week to prevent medication overuse headache 1
• For patients with cardiovascular disease (approximately 20% of migraine patients), avoid triptans and consider NSAIDs or other alternatives 5
• Monitor for medication overuse, which can worsen headache patterns 1
• Educate patients about the importance of a headache diary to identify triggers and monitor treatment response 1

Special Considerations

• Ocular migraine must be distinguished from other causes of transient monocular visual loss 2, 3
• Pattern glare testing may help identify those who are prone to visually triggered migraines 4
• Some patients may benefit from colored filters (particularly blue-to-green spectrum) to reduce visual stress 4

By following this treatment algorithm and considering both pharmacological and non-pharmacological approaches, most patients with ocular migraines can achieve significant improvement in symptoms and quality of life.