What are the treatment options for ocular migraines?

Treatment Options for Ocular Migraines

For ocular migraines, first-line treatment should be NSAIDs, followed by triptans if NSAIDs are ineffective, and then newer agents like ditans or gepants as third-line options. 1, 2

First-Line Treatment Options

• NSAIDs are recommended as initial therapy for most patients with ocular migraines due to their demonstrated efficacy and favorable tolerability 1
  • Effective options include:
    • Aspirin (650-1000 mg every 4-6 hours)
    • Ibuprofen (400-800 mg every 6 hours)
    • Naproxen sodium (275-550 mg every 2-6 hours)
    • Combination of acetaminophen-aspirin-caffeine 1, 2
• Antiemetics should be added if nausea and vomiting are present 1, 2
• Treatment should begin as early as possible during an attack for maximum efficacy 3

Second-Line Treatment Options

• Triptans (serotonin 1B/1D agonists) should be used when NSAIDs fail to provide adequate relief 1
  • Effective options with good evidence include:
    • Oral naratriptan, rizatriptan, sumatriptan, and zolmitriptan
    • Subcutaneous and intranasal sumatriptan (especially useful for patients with nausea and vomiting) 1
• Important caution: Triptans are contraindicated in patients with:
  • Uncontrolled hypertension
  • Risk factors for heart disease
  • Basilar or hemiplegic migraine 1, 2

Third-Line Treatment Options

• For patients who fail triptan therapy or have contraindications, consider:
  • Ditans or gepants 1, 2
  • Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety 1
  • Butorphanol nasal spray may be considered in specific cases 1

Preventive Treatment

• Consider preventive treatment if ocular migraines occur ≥2 days per month despite optimized acute treatment 1
• First-line preventive options include:
  • Beta blockers without intrinsic sympathomimetic activity (atenolol, bisoprolol, metoprolol, propranolol) 1
  • Topiramate 1, 2
  • Candesartan 1
• Second-line preventive options include:
  • Flunarizine
  • Amitriptyline
  • Sodium valproate (contraindicated in women of childbearing potential) 1, 2
• Third-line options include CGRP monoclonal antibodies 1

Complementary Approaches

• Identify and avoid personal triggers through food diaries and lifestyle modifications 4, 5
• Common triggers include:
  • Stress, sleep disturbances, fasting, and hormonal changes 5
  • Visual stimuli (striped patterns, flickering lights) 6
  • Certain foods containing tyramine, phenylethylamine, aspartame, MSG, nitrates, or nitrites 4
  • Alcohol and caffeine 4, 1
• Supplements with some evidence for migraine prevention:
  • Magnesium
  • Petasites hybridus (butterbur)
  • Feverfew
  • Coenzyme Q10
  • Riboflavin
  • Alpha lipoic acid 4

Important Cautions

• Limit acute treatments to no more than twice weekly to prevent medication overuse headaches 1
• Avoid opioids and barbiturates due to risk of dependency and medication overuse headache 2, 3
• Be aware that ocular/retinal migraines can potentially lead to permanent visual loss in some cases, so proper diagnosis and treatment are essential 7
• Consider preventive therapy if medication overuse is suspected or considered to be a risk 1