How to manage ocular (eye) migraines?

Management of Ocular Migraine

For ocular migraine management, implement lifestyle modifications first, followed by acute treatments with NSAIDs and triptans if needed, and consider preventive medications for frequent episodes that impact quality of life. 1, 2

Understanding Ocular Migraine

Ocular migraine (also called retinal or ophthalmic migraine) is an uncommon cause of transient monocular visual loss 3. It's important to distinguish it from more common migraine with visual aura, which typically affects both eyes.

First-Line Management: Lifestyle Modifications

• Maintain a regular lifestyle with consistent sleep patterns and meal times 1, 2
• Identify and avoid personal triggers through a headache diary 2
• Implement stress management techniques 1, 2
• Ensure adequate hydration and regular exercise 1, 2
• Limit caffeine intake 1
• Consider behavioral techniques:
  • Cognitive-behavioral therapy
  • Biofeedback
  • Relaxation training
  • Mindfulness 1, 2

Acute Treatment

For mild to moderate attacks:

1. NSAIDs (first-line): Ibuprofen 400-800mg or naproxen 500-550mg at onset of symptoms 1, 2, 4
2. Add antiemetic if nausea is present (e.g., domperidone or metoclopramide) 1, 2

For moderate to severe attacks or if NSAIDs fail:

1. Triptans (e.g., sumatriptan 25-100mg) 1, 2, 4
   • Take early in the headache phase
   • Avoid in patients with cardiovascular disease
   • Limit use to ≤10 days per month to prevent medication overuse headache

Preventive Treatment

Consider preventive therapy if:

• Attacks occur ≥2 days per month despite optimized acute treatment 1, 2
• Attacks significantly impact quality of life 2
• Risk of medication overuse headache exists 1

First-line preventive options:

• Beta blockers: Propranolol (80-240 mg/day), metoprolol, atenolol, or bisoprolol 1, 2
• Topiramate (start low, typically 25mg, and titrate up to 100mg daily) 1, 2
• Candesartan (16-32mg daily) 1, 2

Second-line preventive options:

• Amitriptyline (10-150mg daily) - particularly useful if comorbid depression or sleep disorders 1, 2
• Flunarizine (where available) 1
• Sodium valproate (in men only, due to teratogenic risk) 1, 2

Nutraceutical options:

• Magnesium citrate (400-600mg daily) 2, 5
• Riboflavin/Vitamin B2 (400mg daily) 2, 5
• Coenzyme Q10 (100-300mg daily) 2, 6

Treatment Algorithm

1. Start with lifestyle modifications for all patients
2. For acute attacks:
   • Mild to moderate: NSAIDs + antiemetic if needed
   • Moderate to severe or NSAID failure: Triptans
3. If ≥2 attacks per month despite acute treatment:
   • Add preventive therapy starting with first-line options
   • Trial for 2-3 months before assessing efficacy
   • If ineffective, try alternative first-line option or move to second-line

Important Considerations

• Medication overuse risk: Limit acute medications to ≤10 days per month 1
• Monitoring: Assess response to preventive treatment after 2-3 months 1, 2
• Pregnancy: Consider magnesium as a safer option 6
• Referral indications:
  • Atypical features
  • Treatment resistance
  • Neurological abnormalities
  • Diagnostic uncertainty 2

Pitfalls to Avoid

• Misdiagnosing ocular migraine (monocular symptoms) as typical migraine with aura (binocular symptoms)
• Overuse of acute medications leading to medication overuse headache
• Inadequate trial duration for preventive medications (minimum 2-3 months needed)
• Failing to address lifestyle factors and triggers
• Using opioids or barbiturates, which should be avoided due to limited efficacy and risk of dependency 1

By following this structured approach to ocular migraine management, most patients can achieve significant improvement in their symptoms and quality of life.