What is the best treatment for ophthalmic migraines?

Treatment of Ophthalmic Migraines

Start with NSAIDs as first-line therapy (ibuprofen, naproxen sodium, diclofenac potassium, or aspirin), and escalate to triptans if NSAIDs fail or for moderate-to-severe attacks. 1, 2

Important Clarification

The term "ophthalmic migraine" typically refers to migraine with visual aura (temporary visual disturbances), which is distinct from "ophthalmoplegic migraine" (a rare condition involving eye muscle paralysis now reclassified as a cranial neuropathy). 3 The treatment approach below addresses the common condition of migraine with visual symptoms.

First-Line Acute Treatment

NSAIDs are the initial treatment of choice for mild-to-moderate attacks: 1, 2

• Acetylsalicylic acid (aspirin), ibuprofen, naproxen sodium, or diclofenac potassium have the strongest evidence for efficacy 1
• Diclofenac potassium may offer faster onset of action (significant relief within 60 minutes) compared to other options 4
• Avoid acetaminophen alone—it is ineffective as monotherapy 1
• The combination of acetaminophen-aspirin-caffeine is effective, but acetaminophen by itself should not be used 1, 5

Critical timing consideration: Start treatment as early as possible during the attack, ideally when pain is still mild, to maximize efficacy 1, 2

Second-Line Treatment

Triptans should be used when NSAIDs provide inadequate relief or for moderate-to-severe attacks: 1, 2

• All triptans have well-documented effectiveness, including sumatriptan, rizatriptan, naratriptan, and zolmitriptan 1
• Sumatriptan 50-100 mg orally is the most studied option, with 100 mg offering better efficacy than 50 mg, though 50 mg has better tolerability 6, 7
• Take triptans early when headache is still mild—do NOT take during the aura phase before headache begins, as this is ineffective 1
• If one triptan fails, try a different triptan, as individual response varies 1, 2
• For rapid-onset severe attacks or when vomiting prevents oral intake, use subcutaneous sumatriptan 6 mg 1, 8

Contraindications to triptans: Uncontrolled hypertension, basilar or hemiplegic migraine, cardiovascular disease risk, or history of ischemic heart disease 1, 8

Combination Therapy

For inadequate response to monotherapy, combine a triptan with an NSAID (naproxen sodium, ibuprofen lysine, or diclofenac potassium): 1, 2

• This combination provides superior efficacy compared to either agent alone 2, 5
• Particularly useful for patients experiencing relapses (return of symptoms within 48 hours) 1

Third-Line Options for Refractory Cases

If all triptans fail after adequate trials (no response in at least three consecutive attacks) or are contraindicated: 1

• Lasmiditan (ditan) has efficacy comparable to triptans but causes temporary driving impairment—patients must not operate machinery for at least 8 hours after intake 1, 2
• Gepants (ubrogepant, rimegepant) are CGRP antagonists that can be used when triptans fail or are contraindicated 1, 2

Adjunctive Treatment

For nausea and vomiting: Add prokinetic antiemetics such as metoclopramide or domperidone 1, 2

For severe nausea/vomiting: Consider non-oral routes of administration (intranasal, subcutaneous, or rectal formulations) 1, 2

Medications to Avoid

• Oral ergot alkaloids are poorly effective and potentially toxic 1, 9
• Opioids and barbiturates have questionable efficacy and high risk of dependency and medication overuse headache 1, 5

Critical Medication Overuse Warning

Limit acute treatment to no more than twice weekly to prevent medication overuse headache: 2, 5

• NSAIDs: ≥15 days per month increases risk 5
• Triptans: ≥10 days per month increases risk 5
• Repeating triptan doses for relapses increases medication overuse headache risk 1

When to Consider Preventive Therapy

Evaluate for preventive treatment if: 1, 5

• Two or more attacks per month causing disability for ≥3 days
• Using rescue medication more than twice weekly
• Acute treatments fail or are contraindicated
• Presence of prolonged aura or other atypical features

First-line preventive agents: Propranolol (80-240 mg/day), timolol (20-30 mg/day), amitriptyline (30-150 mg/day), or divalproex sodium (500-1500 mg/day) 1, 5