What are the treatment options for ocular migraines?

Treatment Options for Ocular Migraines

For ocular migraines, first-line treatment should begin with NSAIDs such as aspirin, ibuprofen, naproxen sodium, or diclofenac potassium, and if these are inadequate, add a triptan to improve efficacy. 1, 2

First-Line Treatment Approach

• NSAIDs are recommended as first-line therapy for most patients with ocular migraines, with options including aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 2, 3
• Treatment should begin as early as possible during an attack for maximum efficacy 2, 4
• Ensure patients are using appropriate dosages of NSAIDs or acetaminophen before considering them ineffective 1
• Combination therapy of acetaminophen plus aspirin plus caffeine can be effective, though acetaminophen alone has limited efficacy 2, 5

Second-Line Treatment Approach

• If patients use an adequate dose of an NSAID or acetaminophen and still do not have sufficient pain relief, add a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated 1
• Triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) are most effective when taken early in an attack while headache is still mild 1, 4
• If one triptan is ineffective, patients may respond to another within the same drug class 1, 4
• For patients with severe nausea or vomiting, consider non-oral triptans or adding an antiemetic such as metoclopramide or prochlorperazine 2, 6

Third-Line Treatment Options

• For patients who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen, consider CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) 1, 4
• Consider using the ditan lasmiditan to treat moderate to severe acute episodic migraine headache in patients who do not tolerate or have inadequate response to all other pharmacologic treatments 1, 3

Important Cautions and Considerations

• Do not use opioids or butalbital for the treatment of acute ocular migraines 1, 2
• Be aware of medication overuse headache, which can develop with frequent use of acute medications (≥15 days per month with NSAIDs; ≥10 days per month with triptans) 1, 4
• Counsel patients to begin treatment as soon as possible after migraine onset, using combination therapy (such as a triptan with an NSAID or acetaminophen) to improve efficacy 1

Preventive Treatment

• If ocular migraines occur frequently or treatment does not provide an adequate response, consider preventive medications 1, 7
• Propranolol is FDA-approved for migraine prophylaxis and can be used to prevent recurrent ocular migraines 7, 4
• Other effective preventive options include beta blockers (atenolol, bisoprolol, metoprolol), topiramate, or candesartan as first-line medications 1, 4
• Second-line preventive medications include flunarizine, amitriptyline or (in men) sodium valproate 1

Lifestyle Modifications

• Highlight the importance of lifestyle modifications with patients, including maintaining adequate hydration, regular meals, sufficient and consistent sleep, regular physical activity, and stress management techniques 1, 4

Remember that ocular migraine is an uncommon cause of transient monocular visual loss, and proper recognition is important for appropriate treatment and to avoid unnecessary testing 8.