What are the treatment options for migraines with aura in a primary care setting?

Treatment Options for Migraines with Aura in Primary Care

For acute treatment of migraine with aura, primary care providers should add a triptan to a nonsteroidal anti-inflammatory drug (NSAID) for patients with moderate to severe attacks who do not respond adequately to NSAIDs alone. 1

Acute Treatment Algorithm

First-Line Options

• NSAIDs (acetylsalicylic acid, ibuprofen, or diclofenac potassium) should be started as soon as possible during the aura phase to prevent or diminish the headache phase 1, 2
• NSAIDs are recommended as first-line medication for acute treatment of migraine attacks 1
• Treatment during the aura phase is aimed at preventing the headache phase rather than treating the aura itself 2

Second-Line Options

• Triptans (such as sumatriptan) should be added when patients do not respond adequately to NSAIDs alone 1
• Sumatriptan is FDA-approved for acute treatment of migraine with or without aura in adults 3
• Oral sumatriptan doses of 25mg, 50mg, or 100mg are effective for treating acute migraine attacks 3, 4
• Triptans should be used when the headache begins, not during the aura phase according to traditional recommendations 2
• However, recent research suggests that sumatriptan treatment during the aura phase may preempt headache development in some patients 5

Combination Therapy

• Adding a triptan to acetaminophen is suggested for patients who don't respond adequately to acetaminophen alone 1
• The combination of a triptan with an NSAID provides better relief than either medication alone for moderate to severe attacks 1

Important Considerations and Contraindications

• Triptans are contraindicated in patients with:

  • History of coronary artery disease or coronary vasospasm 3
  • Wolff-Parkinson-White syndrome or other cardiac conduction disorders 3
  • History of stroke, transient ischemic attack, or hemiplegic/basilar migraine 3
  • Peripheral vascular disease or ischemic bowel disease 3
  • Uncontrolled hypertension 3, 6

• Medication overuse headache is a risk with frequent use of acute medications (≥15 days/month for NSAIDs) 7

• Maximum dose of sumatriptan in a 24-hour period should not exceed 200mg 3

• A second dose of sumatriptan should only be considered if some response to the first dose was observed, with doses separated by at least 2 hours 3

Preventive Treatment Options

• Preventive treatment should be considered when migraine attacks adversely affect the patient on ≥2 days per month despite optimized acute treatment 7
• Evidence-based preventive options for migraine with aura include:
  • Topiramate has evidence supporting its use in chronic migraine 1
  • Beta-blockers (propranolol, metoprolol) are effective prophylactic options 7
  • Amitriptyline is recommended particularly when there are comorbid sleep disturbances 7
  • Candesartan is another option with evidence for migraine prophylaxis 7
  • CGRP monoclonal antibodies (like erenumab) have shown efficacy in reducing monthly migraine days 8

Non-Pharmacological Approaches

• Maintain a headache/migraine diary to identify triggers and monitor treatment effectiveness 7
• Implement lifestyle modifications including regular meals, consistent sleep patterns, stress management, and hydration 7
• Regular exercise (40 minutes three times weekly) can be as effective as some preventive medications 7
• Cognitive behavioral therapy, relaxation training, or biofeedback have shown efficacy for migraine management 7

Special Populations

• For pregnant women, paracetamol (acetaminophen) is the safest option for acute treatment; preventive medications should be avoided if possible 7
• In older adults, carefully monitor for adverse effects of medications, particularly with triptans if cardiovascular risk factors are present 7
• Women with migraine with aura should avoid combined hormonal contraception with estrogens due to significantly increased stroke risk 2

Follow-Up Management

• Schedule regular follow-up visits to monitor frequency, severity, and response to treatment 7
• Use standardized assessment tools to monitor progress 7
• Adjust treatment based on response and tolerability 7
• Consider discontinuing preventive medication after 3-6 months of stability 7