What is the treatment for cognitive migraines?

Treatment for Cognitive Migraines

First-line treatment for cognitive migraines should include NSAIDs (such as ibuprofen 400-800mg or naproxen 500-550mg) for acute attacks, with propranolol (80-240 mg/day) as the preferred preventive medication for patients experiencing frequent attacks. 1

Understanding Cognitive Symptoms in Migraine

Migraine can present with various cognitive symptoms, which are typically part of the aura phase that precedes or accompanies the headache. These cognitive symptoms may include:

• Difficulty concentrating
• Memory issues
• Language disturbances (aphasia)
• Mental confusion
• Difficulty finding words

These symptoms are part of the neurological manifestations of migraine aura, which can also include visual disturbances, sensory symptoms, and other focal neurological symptoms 2.

Acute Treatment Algorithm

1. First-line medications:

   • NSAIDs (ibuprofen 400-800mg or naproxen 500-550mg) taken as early as possible during an attack 1
   • Acetaminophen alone is not recommended due to limited efficacy evidence 1

2. Second-line medications (if NSAIDs provide insufficient relief):

   • Triptans (e.g., sumatriptan) 2, 1
   • When using triptans, be aware of contraindications including:
     • Wolff-Parkinson-White syndrome
     • Coronary artery disease
     • Prinzmetal's variant angina
     • History of stroke or TIA 3

3. For severe nausea/vomiting:

   • Consider non-oral triptans with antiemetics 1

4. Medication limits:

   • Restrict acute medications to ≤10 days per month to prevent medication overuse headache 1

Preventive Treatment Algorithm

Initiate preventive treatment if the patient experiences:

• 4 or more migraine days per month
• 2 or more attacks per month producing disability lasting 3+ days per month
• Use of acute medications more than twice per week
• Contraindication to or failure of acute treatments 1

1. First-line preventive options:

   • Propranolol (80-240 mg/day) - strong evidence for efficacy 1
   • Timolol (20-30 mg/day) - alternative beta-blocker 1
   • Topiramate (50-200 mg/day) - effective for both episodic and chronic migraine 1
   • Amitriptyline (30-150 mg/day) - particularly beneficial for patients with comorbid depression or sleep disturbances 1

2. Start low and go slow:

   • Begin at a low dose and gradually increase until desired outcomes are achieved
   • Allow 2-3 months to properly assess efficacy before determining treatment failure 1

3. For chronic migraine (≥15 headache days/month for >3 months, with ≥8 days having migraine features):

   • Topiramate
   • OnabotulinumtoxinA
   • CGRP monoclonal antibodies 1

Non-Pharmacological Approaches

These should be implemented alongside medication:

• Regular aerobic exercise (30 minutes of moderate activity most days)
• Maintaining regular sleep patterns
• Regular meal times and adequate hydration
• Stress management techniques (relaxation training, meditation, biofeedback)
• Cognitive-behavioral therapy 1

Special Considerations

• For pregnant women: Use paracetamol (acetaminophen) for acute treatment and avoid preventive treatment if possible 2
• For older patients: Be cautious as secondary headache, comorbidities, and adverse events are more likely 2
• For patients with comorbidities: Select medications that may benefit both conditions (e.g., propranolol for patients with hypertension or tachycardia) 2

Red Flags Requiring Further Evaluation

Urgent evaluation is needed for:

• Sudden, severe "thunderclap" headache
• Headache with fever, stiff neck, confusion
• Headache after head injury
• New headache with neurological symptoms
• Headache worsened with Valsalva maneuver or that awakens from sleep 1

Treatment Monitoring

• Use headache calendars to track frequency, severity, and medication use
• Assess effectiveness and adverse events
• When outcomes are suboptimal, review diagnosis, treatment strategy, dosing, and adherence 2

Remember that cognitive symptoms during migraine can be distressing but are typically reversible. Proper acute and preventive treatment can significantly reduce the frequency and severity of these episodes.