What is the treatment for ocular migraines?

Treatment for Ocular Migraines

For ocular migraines, first-line treatment includes NSAIDs such as aspirin, ibuprofen, or naproxen sodium, with triptans recommended as second-line therapy when NSAIDs fail to provide adequate relief. 1, 2

Acute Treatment Algorithm

First-Line Therapy

• NSAIDs are recommended as first-line therapy for most migraine sufferers, including those with ocular symptoms 1, 2
  • Aspirin, ibuprofen, and naproxen sodium have the most consistent evidence for efficacy 1
  • The combination of acetaminophen plus aspirin plus caffeine is also effective 1
  • Start treatment as early as possible in the headache phase for maximum effectiveness 2

Second-Line Therapy

• If NSAIDs are ineffective, use migraine-specific agents such as triptans 1, 2
  • Oral triptans with good evidence include naratriptan, rizatriptan, zolmitriptan, and sumatriptan 1, 3
  • Sumatriptan works by binding to 5-HT1B/1D receptors, causing cranial vessel constriction and inhibiting pro-inflammatory neuropeptide release 3
  • Consider non-oral routes of administration (nasal spray, subcutaneous injection) if nausea or vomiting is significant 1

Managing Associated Symptoms

• For migraines with significant nausea or vomiting, add an antiemetic medication 1, 2
  • Antiemetics should not be restricted to patients who are vomiting but should also be used for nausea itself 1
  • Consider non-oral routes of administration if vomiting occurs early in the attack 1, 2

Preventive Treatment

Indications for Preventive Therapy

• Consider preventive therapy for patients experiencing: 1, 4
  • Two or more attacks per month with disability lasting 3+ days per month
  • Use of acute medications more than twice weekly
  • Contraindication to or failure of acute treatments
  • Uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura)

First-Line Preventive Medications

• Beta-blockers: propranolol (80-240 mg/day) and timolol (20-30 mg/day) 1, 4, 5
  • Propranolol is FDA-approved for migraine prophylaxis 5
• Tricyclic antidepressants: amitriptyline (30-150 mg/day) 1, 4, 6
• Anticonvulsants: divalproex sodium (500-1500 mg/day) and topiramate 1, 4, 7

Newer Preventive Options

• CGRP-targeted therapies have demonstrated efficacy in migraine prevention 8
  • Injectable monoclonal antibodies (eptinezumab, erenumab, fremanezumab, galcanezumab)
  • Oral CGRP receptor antagonists (atogepant, rimegepant)

Important Clinical Considerations

Medication Administration

• Start preventive medications at a low dose and titrate slowly 1, 4
• Allow 2-3 months for full therapeutic effect of preventive medications 1
• After a period of stability (6-12 months), consider tapering or discontinuing preventive treatment 1, 9

Avoiding Common Pitfalls

• Limit acute treatments to no more than twice weekly to prevent medication overuse headache 2, 4, 10
• Avoid acetaminophen alone as there is no evidence for its efficacy in migraine 1
• Be cautious with triptans in patients with cardiovascular risk factors 3
• For women of childbearing potential, discuss potential teratogenic effects of certain preventive medications, particularly valproate and topiramate 4, 3

Special Populations

• Triptans are not recommended for patients under 18 years of age 3
• In elderly patients, start with lower doses and monitor for adverse effects, particularly with cardiovascular risk factors 3
• In patients with hepatic impairment, maximum single dose of sumatriptan should not exceed 50 mg 3