What is the treatment for ocular migraines?

Treatment for Ocular Migraines

For acute treatment of ocular migraines, start with NSAIDs (aspirin, ibuprofen, or naproxen sodium) as first-line therapy, and escalate to triptans if NSAIDs fail to provide relief within 2 hours. 1

Acute Treatment Algorithm

First-Line: NSAIDs

• Initiate treatment with aspirin, ibuprofen, or naproxen sodium immediately at symptom onset for maximum effectiveness 2, 1
• The combination of acetaminophen plus aspirin plus caffeine is also effective and represents an alternative first-line option 2, 1
• Do not use acetaminophen alone—there is no evidence supporting its efficacy in migraine 2, 1
• The goal is to restore full function within 2 hours of treatment 3

Second-Line: Triptans (If NSAIDs Ineffective)

• Switch to oral triptans when NSAIDs fail to provide adequate relief 2, 1
• Effective oral triptans include naratriptan, rizatriptan, zolmitriptan, and sumatriptan 2, 1
• Consider non-oral routes (nasal spray or subcutaneous injection) if nausea or vomiting accompanies the visual symptoms 2, 1
• Subcutaneous sumatriptan and DHE nasal spray have good evidence for efficacy 2

Critical Pitfall to Avoid

• Limit acute medication use to no more than twice weekly to prevent medication overuse headache, which can worsen migraine frequency 1, 4

Preventive Treatment Indications

Consider preventive therapy if you experience two or more attacks per month causing disability lasting 3+ days, or if you're using acute medications more than twice weekly. 1, 4

First-Line Preventive Medications

The American College of Physicians and American Academy of Neurology recommend the following as first-line options 1, 4, 5:

Beta-Blockers

• Propranolol 80-240 mg/day 1, 4
• Timolol 20-30 mg/day 1, 4
• These are particularly useful if you have coexisting hypertension 6

Tricyclic Antidepressants

• Amitriptyline 30-150 mg/day 1, 4, 5
• Especially beneficial if you have coexisting depression or tension-type headaches 6

Anticonvulsants

• Divalproex sodium 500-1,500 mg/day 1, 4, 5
• Topiramate (dose varies) 1, 4, 5
• Critical warning for women of childbearing potential: Both valproate and topiramate are teratogenic—discuss effective contraception and folate supplementation before prescribing 1, 4

Second-Line Options

• ACE inhibitors (lisinopril) or ARBs (candesartan, telmisartan) if first-line agents fail or are not tolerated 4

Implementation Strategy

Dosing Approach

• Start at the lowest dose and titrate slowly upward to minimize side effects 2, 1, 4
• Allow 2-3 months for full therapeutic effect before judging efficacy—this is a common pitfall where patients and clinicians discontinue treatment prematurely 2, 1, 4
• Maintain a headache diary during this period to objectively assess response 6

Duration of Preventive Therapy

• Continue successful preventive treatment for 6-12 months 6
• After achieving stability, attempt to taper the dose to find the minimum effective dose or discontinue if appropriate 2, 6

Addressing Comorbidities

• Select preventive medications that can treat both migraine and coexisting conditions (e.g., beta-blockers for hypertension, amitriptyline for depression) 5, 6
• Avoid beta-blockers in patients who practice sports or have frequent attacks with aura 6
• Consider weight gain potential when treating young women—this may affect compliance 6

Non-Pharmacologic Approaches

• Cognitive behavioral therapy and relaxation training have proven efficacy for migraine prevention 4
• Address modifiable triggers: maintain regular sleep patterns, adequate hydration, regular physical activity, and stress management 4