What are the treatment options for migraine with aura?

Treatment Options for Migraine with Aura

For migraine with aura, first-line acute treatment includes NSAIDs or aspirin started during the aura phase, followed by triptans when headache begins, while preventive options include topiramate, beta-blockers (particularly propranolol), and CGRP monoclonal antibodies for those who fail other preventives. 1, 2, 3

Acute Treatment

First-Line Options

• Start NSAIDs or aspirin as early as possible during the aura phase to prevent or reduce the headache phase 3
• If NSAIDs/aspirin fail, use triptans when the headache begins (not during aura) 3
  • Sumatriptan has proven efficacy for migraine with or without aura 4
  • Available doses: 25mg, 50mg, 100mg (50mg is often sufficient; doses above 50mg may not provide additional benefit) 4
  • Sumatriptan's efficacy is unaffected by the presence of aura 4

Second-Line Options

• Antiemetics and ergot alkaloids for refractory cases 5
• Gepants and ditans are newer alternatives that don't have vascular contraindications (unlike triptans) 5

Medications to Avoid

• Opioids and butalbital-containing medications are not recommended unless other options have failed 5

Preventive Treatment

First-Line Preventive Options

• Topiramate - evidence-based option specifically for migraine with aura 1, 2
• Beta-blockers (particularly propranolol 80-240 mg/day) 2, 6
• Amitriptyline - especially beneficial for patients with depression or sleep disturbances 1, 2, 6

Second-Line/Refractory Cases

• OnabotulinumtoxinA (Botox) - for chronic migraine after failure of other preventives 1, 2
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) - proven beneficial for patients in whom at least two other preventive medications have failed 1, 2
• Angiotensin receptor blockers (candesartan/telmisartan) 2

Experimental Option for Migraine with Aura

• Lamotrigine - may specifically reduce frequency and severity of aura symptoms, though not officially recommended for general migraine prevention 7

Special Considerations for Migraine with Aura

Cardiovascular Risk

• Women with migraine with aura have significantly higher risk of ischemic stroke (RR 2.08) 2, 3
• Risk further increases with:
  • Age <45 years (RR 3.65)
  • Smoking (RR 9.03)
  • Oral contraceptive use (RR 7.02) 2

Contraception and Hormone Therapy

• Combined hormonal contraceptives with estrogens are contraindicated in women with migraine with aura due to significantly increased stroke risk 2, 3
• Avoid hormone replacement therapy (HRT) with estrogen 2

Non-Pharmacological Approaches

Lifestyle Modifications

• Maintain a headache diary to identify triggers
• Regular aerobic exercise (as effective as relaxation therapy or topiramate in some studies)
• Address modifiable risk factors:
  • Obesity
  • Medication overuse
  • Caffeine use
  • Sleep disturbances
  • Stress 2

Supplements

• Oral magnesium (400-600mg daily) - most evidence-supported supplement for migraine prevention 2

When to Refer to a Specialist

• Failure of two or more preventive medication trials
• Uncertain diagnosis
• Complex comorbidities
• Need for advanced treatments like onabotulinumtoxinA 2

Diagnostic Considerations

• Aura symptoms typically develop gradually, last less than one hour, and are fully reversible
• Visual aura is most common (>90% of patients)
• When multiple aura symptoms occur, they typically follow in succession (visual → sensory → aphasic)
• Emergency evaluation is needed if:
  • Symptoms correspond to a cerebral vascular territory
  • Aura lasts longer than one hour
  • Late onset of aura
  • Dramatic increase in aura attacks 3