What are the treatment options for optical migraines?

Treatment of Optical Migraines

Start with NSAIDs (aspirin, ibuprofen, naproxen, or diclofenac) as first-line therapy, and if inadequate relief occurs, add a triptan to the NSAID for combination therapy. 1

Acute Treatment Algorithm

First-Line: NSAIDs

• Begin treatment with over-the-counter NSAIDs as soon as the optical migraine begins 1
• Effective options include aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1
• Ensure you are using appropriate therapeutic dosages before concluding NSAIDs are ineffective 1
• Acetaminophen can be used if NSAIDs are contraindicated or not tolerated, though it has less efficacy 2

Second-Line: Add Triptans

• If NSAIDs alone provide insufficient pain relief, add a triptan to the NSAID (or to acetaminophen when NSAIDs cannot be used) 1
• Triptans work best when taken early in the attack while headache is still mild 2, 1
• The combination of a triptan plus NSAID is more effective than either agent alone 2
• If one triptan fails, try a different triptan as individual responses vary 2

Available Triptan Options

• Oral triptans include sumatriptan, rizatriptan, naratriptan, and zolmitriptan 3
• Rizatriptan achieves headache response (reduction to no or mild pain) in 60-77% of patients within 2 hours, compared to 23-40% with placebo 3
• For patients with severe nausea or vomiting who cannot tolerate oral medications, subcutaneous sumatriptan injection is an effective alternative 2

Critical Medications to Avoid

• Never use opioids or butalbital-containing medications for optical migraines 1
• These agents have questionable efficacy, significant adverse effects, and risk of dependency 1

Medication Overuse Prevention

• Limit NSAID use to ≤15 days per month to prevent medication overuse headache 2, 1
• Limit triptan use to ≤10 days per month to prevent medication overuse headache 2, 1
• Monitor frequency of acute medication use carefully, as overuse can paradoxically worsen headache patterns 1

Advanced Treatment Options

If all triptans fail or are contraindicated, consider:

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 2
• Dihydroergotamine (DHE) 2
• Lasmiditan (ditan) 2

When to Consider Preventive Therapy

Preventive medications should be considered if: 2, 1

• Two or more attacks occur per month producing disability lasting 3+ days per month 2
• Acute treatments are contraindicated or have failed 2
• Acute medications are being used more than twice per week 2
• Uncommon migraine conditions are present (hemiplegic migraine, migraine with prolonged aura) 2

First-Line Preventive Options

• Beta-blockers 1
• Topiramate (discuss teratogenic effects with patients of childbearing potential) 2, 1
• Candesartan 1

Essential Lifestyle Modifications

• Maintain regular meals and adequate hydration 2, 1
• Ensure sufficient and consistent sleep 2, 1
• Engage in regular moderate to intense aerobic exercise 2, 1
• Practice stress management techniques including relaxation or mindfulness 2, 1
• Address poor sleep quality, poor physical fitness, and stress as predisposing factors 2