What is the treatment for a migraine with aura accompanied by right-sided numbness?

Treatment of Migraine with Aura and Right-Side Numbness

For migraine with aura accompanied by right-sided numbness, first-line treatment should begin with NSAIDs (such as ibuprofen 400-800mg) or triptans (such as sumatriptan 50-100mg) at the onset of headache phase, not during the aura phase. 1, 2

Understanding Migraine with Aura and Sensory Symptoms

Migraine with aura is characterized by fully reversible neurological symptoms that typically precede the headache phase. When sensory symptoms like right-sided numbness occur:

• Visual aura is most common (>90% of cases), but sensory aura (like numbness) occurs in a significant subset of patients 2
• Aura symptoms develop gradually (≥5 minutes) and typically last 5-60 minutes 1, 3
• Symptoms often occur in succession (visual → sensory → speech) 2
• Sensory symptoms like numbness are usually unilateral and can include both positive (tingling) and negative (numbness) phenomena 3

Acute Treatment Algorithm

Step 1: During Aura Phase

• Begin NSAIDs or aspirin as soon as possible during the aura phase (not to treat the aura but to prevent or reduce the headache phase) 2
  • Ibuprofen 400-800mg
  • Naproxen sodium 275-550mg
  • Aspirin 650-1000mg

Step 2: At Onset of Headache Phase

• If NSAIDs were ineffective during aura, use a triptan when the headache begins 2
  • Sumatriptan 50-100mg orally (most evidence-based option) 4
  • Take early in the attack when pain is still mild 1
  • Do NOT use triptans during the aura phase itself 1

Step 3: For Inadequate Relief

• If first triptan dose provides inadequate relief, may repeat dose after 2 hours 4
• Maximum sumatriptan dosage: 200mg in 24 hours 4
• Consider combination therapy: triptan plus NSAID (e.g., sumatriptan plus naproxen) 1

Step 4: Rescue Therapy for Severe Attacks

• For severe attacks unresponsive to above treatments:
  • Antiemetics like metoclopramide or prochlorperazine for associated nausea and pain 1
  • In extreme cases, consider parenteral options in emergency settings

Important Considerations and Precautions

Differential Diagnosis

• Distinguish migraine with aura from transient ischemic attack (TIA):
  • Migraine aura: symptoms develop gradually (≥5 min), occur in succession
  • TIA: symptoms have sudden, simultaneous onset 1, 3
  • Consider brain imaging if presentation is atypical 5

Contraindications and Cautions

• Triptans are contraindicated in:

  • History of coronary artery disease or stroke
  • Uncontrolled hypertension
  • Hemiplegic or basilar migraine
  • Use within 24 hours of another triptan or ergotamine 4

• For women with migraine with aura:

  • Combined hormonal contraceptives are absolutely contraindicated due to increased stroke risk 1, 2

Medication Overuse Risk

• Limit use of acute medications to avoid medication overuse headache:
  • NSAIDs: ≤15 days/month
  • Triptans: ≤10 days/month 1

Preventive Treatment

Consider preventive therapy if:

• Attacks are frequent (≥4/month)
• Attacks are debilitating despite acute treatment
• Acute medications are contraindicated or ineffective

First-line preventive options include:

• Beta-blockers (propranolol 80-160mg daily, metoprolol 50-100mg twice daily)
• Topiramate (50-100mg daily)
• Candesartan (16-32mg daily) 1

For patients with pure menstrual migraine with aura, perimenstrual preventive treatment may be considered, but combined hormonal contraceptives are contraindicated 1.

Follow-up and Monitoring

Evaluate treatment response within 2-3 months, assessing:

• Attack frequency
• Attack severity
• Migraine-related disability
• Medication use/potential overuse 1

Headache calendars are extremely useful for tracking these outcomes and guiding treatment adjustments.

Note: While this treatment approach is evidence-based, individual factors such as comorbidities and previous treatment responses should be considered.