What is the treatment for ocular migraines?

Treatment of Ocular Migraines

For acute ocular migraine attacks, NSAIDs (aspirin 650-1000mg, ibuprofen 400-800mg, or naproxen sodium 275-550mg) are first-line therapy for mild-to-moderate symptoms, with escalation to triptans (sumatriptan, rizatriptan, zolmitriptan) if inadequate response occurs within 2 hours or for moderate-to-severe attacks. 1, 2

Acute Treatment Algorithm

First-Line Therapy

• Start with NSAIDs for mild-to-moderate ocular migraine attacks: aspirin 650-1000mg, ibuprofen 400-800mg, or naproxen sodium 275-550mg 1, 2
• Combination analgesics containing caffeine (aspirin plus acetaminophen plus caffeine) demonstrate superior efficacy compared to single agents 1
• Acetaminophen alone lacks evidence for efficacy and should not be used as monotherapy 2

Escalation Strategy

• If inadequate response within 2 hours, escalate to a triptan (sumatriptan, naratriptan, rizatriptan, or zolmitriptan) 1, 2
• For moderate-to-severe attacks from onset, triptans are recommended as first-line therapy 1, 2
• Triptans are most effective when taken early while headache is still mild 1
• If one triptan is ineffective, trial of alternative triptans is reasonable as individual response varies 1

Route of Administration Considerations

• For attacks with significant nausea or vomiting, select non-oral routes: subcutaneous sumatriptan or nasal spray formulations 1, 2
• Subcutaneous sumatriptan is most effective when oral medications fail or when patients rapidly reach peak headache intensity 1, 2

Adjunctive Therapy

• Add antiemetics (metoclopramide or prochlorperazine) to treat accompanying nausea and improve gastric motility 1, 2
• Prochlorperazine provides additional headache pain relief beyond nausea control 1
• Caffeine can be used for synergistic analgesia 1

Preventive Treatment

Consider preventive therapy for patients adversely affected by ocular migraines on ≥2 days per month despite optimized acute treatment. 3

First-Line Preventive Medications

• Beta blockers (atenolol, bisoprolol, metoprolol, or propranolol) 3
• Topiramate 3
• Candesartan 3
• Note: Propranolol is FDA-approved for migraine prophylaxis but is not indicated for treating acute attacks that have already started 4

Second-Line Preventive Medications

• Flunarizine 3
• Amitriptyline 3
• Sodium valproate (in men only) 3

Third-Line Preventive Medications

• CGRP monoclonal antibodies when first-line and second-line preventive drugs have failed or are contraindicated 3

Non-Pharmacological Preventive Options

• Neuromodulatory devices have supporting evidence as adjuncts or stand-alone therapy when medication is contraindicated 3
• Biobehavioral therapy can be considered 3
• Acupuncture has some evidence, though not superior to sham acupuncture 3

Critical Cautions

Medication Overuse

• Avoid overuse of analgesics as this leads to medication overuse headache (MOH) 1
• Limit and carefully monitor opioids and butalbital-containing analgesics due to dependency risk and rebound headaches 1
• Abrupt withdrawal of overused medication is preferred (except for opioids) 3

Cardiovascular Considerations

• Triptans should be avoided in patients with cardiovascular disease or significant cardiovascular risk factors 1
• While no robust evidence supports increased cardiovascular events in older patients using triptans, regular blood pressure monitoring and periodic cardiovascular risk assessment is advised 3

Important Clinical Context

Ocular migraine represents transient monocular visual loss associated with migraine headache, typically lasting less than 1 hour with full reversibility 5. However, nearly half of patients with recurrent transient monocular visual loss may subsequently experience permanent monocular visual loss, indicating that irreversible visual loss is part of the retinal migraine spectrum 5. When persistent visual field defects occur—even if migraine is suspected—appropriate workup must be performed to rule out other causes of vision loss, including neurologic evaluation, head imaging, and laboratory testing 6.

The efficacy of propranolol and other preventive medications in treating an acute ocular migraine attack that has already started has not been established; these agents are indicated only for prophylaxis 4.