What is the best treatment approach for a patient with migraine with aura and lasting visual changes?

Management of Migraine with Aura and Lasting Visual Changes

For patients with migraine with aura and lasting visual changes, first-line treatment should include NSAIDs started during the aura phase, followed by triptans if needed when the headache begins, with topiramate as the preferred preventive medication for patients with frequent attacks. 1, 2, 3

Acute Treatment Approach

First-Line Treatment

• Start NSAIDs (ibuprofen 400-800mg) or aspirin as soon as possible during the aura phase
  • These medications won't treat the aura but may prevent or reduce the headache phase 3
  • Acetaminophen (paracetamol) should only be used if patient is intolerant to NSAIDs 2

Second-Line Treatment

• If NSAIDs are ineffective when the headache begins, add a triptan such as sumatriptan
  • Standard dosing: 25-100mg orally 4
  • Do not exceed 200mg in a 24-hour period 4
  • Maximum single dose should not exceed 50mg in patients with mild to moderate hepatic impairment 4
  • Separate doses by at least 2 hours if a second dose is needed 4

Important Cautions for Triptans

• Contraindications: History of coronary artery disease, stroke, TIA, hemiplegic or basilar migraine, peripheral vascular disease, uncontrolled hypertension 4
• Do not use triptans during the aura phase itself - wait until headache begins 2, 3
• Limit acute medications to ≤10 days per month to prevent medication overuse headache 2

Preventive Treatment for Frequent Migraine with Aura

First-Line Preventive Options

• Topiramate: Start at 25mg daily and increase to 50-100mg daily 2
  • Approximately 75% of patients respond to treatment 5
  • About 25% respond to lower doses (50mg daily), while about 50% require 100mg daily 5
  • While effective for reducing migraine frequency, some studies suggest topiramate may not specifically reduce aura frequency or duration 6

Alternative Preventive Options

• Beta-blockers (if no contraindications):

  • Propranolol 80-160mg daily in long-acting formulations 1
  • Metoprolol 50-100mg twice daily or 200mg modified-release once daily 1
  • Atenolol 25-100mg twice daily 1
  • Contraindicated in asthma, cardiac failure, Raynaud disease 1

• Amitriptyline: 10-100mg oral at night 1

  • Particularly useful if comorbid depression or anxiety 2
  • Contraindicated in heart failure, glaucoma 1

• Candesartan: 16-32mg oral per day 1

Special Considerations for Migraine with Aura

Hormonal Contraception Warning

• Combined hormonal contraceptives are contraindicated in women with migraine with aura due to increased stroke risk 1, 3
• This applies regardless of any association with the menstrual cycle 1

Distinguishing Aura from TIA

• Aura symptoms typically spread gradually (over ≥5 min) and occur in succession
• TIA symptoms have a sudden, simultaneous onset 1
• Visual aura is most common (>90% of patients) 3

Red Flags Requiring Further Evaluation

• Sudden onset of neurological symptoms (rather than gradual)
• Symptoms corresponding to a specific cerebrovascular territory
• Aura lasting longer than one hour (except motor symptoms)
• Late onset of aura or dramatic increase in aura attacks 3

Monitoring and Follow-up

• Use headache calendars to track frequency, severity, and medication use 1, 2
• Evaluate treatment response within 2-3 months after initiation or change in treatment 1
• Assess effectiveness, adverse events, and adherence 1
• For preventive medications, follow up after 4-6 weeks to assess improvement and monitor for adverse effects 2

Management of Persistent Visual Changes

• If visual changes persist beyond the typical aura duration (5-60 minutes), consider neuroimaging (CT or MRI) to rule out other causes 2
• Refer to a neurologist if symptoms are atypical, persistent, or refractory to treatment 2

By following this structured approach, most patients with migraine with aura and lasting visual changes can achieve significant improvement in their symptoms and quality of life.