What is the treatment for ocular migraines?

Treatment of Ocular Migraines

NSAIDs such as ibuprofen (400-600mg) or naproxen sodium (500-550mg) are the first-line treatment for ocular migraines, with triptans recommended as second-line therapy when NSAIDs are ineffective. 1, 2

Understanding Ocular Migraines

Ocular migraines (also called retinal migraines) are characterized by:

• Periodic loss of vision in one eye typically lasting 30 minutes or less 3
• May be followed by headache
• Most common in women of childbearing age with a history of migraine with aura 4
• Visual symptoms include partial or complete monocular visual loss

Acute Treatment Algorithm

First-Line Treatment

• NSAIDs with antiemetic if necessary 1, 2
  • Ibuprofen 400-600mg with food
  • Naproxen sodium 500-550mg with food
  • Take early in the headache phase for maximum effectiveness

Second-Line Treatment (if NSAIDs fail after three attacks)

• Triptans 1, 2, 5
  • Sumatriptan 50mg orally (maximum 200mg in 24 hours)
  • Consider subcutaneous sumatriptan 6mg for severe attacks or significant nausea/vomiting

Third-Line Treatment (if triptans fail)

• Ditans or gepants 1, 2
  • Lasmiditan (ditan) - Note: Do not operate machinery for at least 8 hours after intake
  • Ubrogepant or rimegepant (gepants)

Adjunct Medications

• For nausea/vomiting: Prokinetic antiemetics such as domperidone or metoclopramide 1

Medications to Avoid

• Oral ergot alkaloids (poorly effective and potentially toxic) 1
• Opioids and barbiturates (questionable efficacy, risk of dependency) 1, 2

Preventive Treatment

Consider preventive treatment if ocular migraines occur ≥2 times per month with significant disability despite optimized acute therapy 1, 2:

First-Line Preventive Options

• Beta blockers 1, 2, 6
  • Propranolol 80-240 mg/day (FDA-approved for migraine prophylaxis)
  • Metoprolol, atenolol, or bisoprolol are alternatives
• Candesartan 1

Second-Line Preventive Options

• Amitriptyline (30-150 mg/day) - particularly effective if sleep disturbance is present 1, 2
• Flunarizine 1
• Sodium valproate (in men only) 1

Third-Line Preventive Options

• CGRP monoclonal antibodies for refractory cases 1, 2

Non-Pharmacological Approaches

These can be used as adjuncts or standalone treatments when medications are contraindicated:

• Neuromodulatory devices 1, 2
• Biobehavioral therapy 1
• Acupuncture 1
• Regular sleep schedule and adequate hydration 2
• Identification and avoidance of triggers 2
• Regular aerobic exercise 2

Important Considerations

• Assess treatment efficacy after 2-3 months for oral preventives and 3-6 months for CGRP monoclonal antibodies 1
• Limit acute medications to prevent medication overuse headache:
  • NSAIDs: <15 days/month
  • Triptans: <9 days/month
  • OTC medications: <14 days/month 2
• Be aware that some ocular migraines may lead to permanent visual loss - nearly half of reported cases with recurrent transient monocular visual loss eventually experienced permanent monocular visual loss 4
• If topiramate is used for prevention, monitor for eyelid myokymia, which has been reported in 5.7% of migraine patients taking this medication 7

Special Populations

• Older adults: Consider cardiovascular risk factors before prescribing triptans 5
• Pregnancy: Sumatriptan should be used during pregnancy only if potential benefit justifies potential risk to the fetus 5
• Nursing mothers: Avoid breastfeeding for 12 hours after sumatriptan treatment 5
• Pediatric patients: Safety and effectiveness of sumatriptan not established in patients under 18 years 5