What is the best treatment approach for a patient experiencing migraine aura?

Treatment of Migraine Aura

Start NSAIDs or aspirin immediately when aura symptoms begin to prevent or reduce the subsequent headache phase, and if this fails, use triptans once the headache starts—but never during the aura itself. 1, 2

Acute Treatment Algorithm

During the Aura Phase (First 5-60 minutes)

• Initiate NSAIDs or aspirin as soon as aura symptoms appear to abort or diminish the headache that typically follows within 60 minutes 1, 2
• The goal is not to treat the aura symptoms themselves (which are self-limited and resolve spontaneously), but to preemptively address the impending headache phase 2
• Do NOT use triptans during the aura phase due to theoretical concerns about vasoconstriction during a period of potential cortical hypoperfusion 1, 2

When Headache Begins (After Aura)

• If NSAIDs or aspirin fail, administer a triptan when the headache phase starts 1, 2
• Sumatriptan tablets are FDA-approved for acute treatment of migraine with or without aura in adults, with dosing options of 25 mg, 50 mg, or 100 mg 3
• The 50 mg and 100 mg doses show superior efficacy compared to 25 mg, with 61-62% of patients achieving headache response at 2 hours versus 52% with 25 mg 3
• There is no evidence that doses above 50 mg provide greater effect than 50 mg 3
• A second dose may be considered only if some response to the first dose was observed, separated by at least 2 hours, with a maximum of 200 mg in 24 hours 3

Critical Safety Considerations

Contraindications in Migraine with Aura

• All combined hormonal contraceptives containing estrogen are absolutely contraindicated in women with migraine with aura due to compounded stroke risk 1
• Women with migraine with aura have significantly elevated baseline risk of ischemic stroke, and estrogen-containing contraceptives further increase this risk 1
• Progestin-only contraceptives (including progestin-only pills like Slinda) are safe alternatives 1

Triptan Contraindications

• History of coronary artery disease, stroke, transient ischemic attack, hemiplegic or basilar migraine 3
• Peripheral vascular disease, ischemic bowel disease, uncontrolled hypertension 3
• Recent use (within 24 hours) of another triptan or ergotamine-containing medication 3

Preventive Treatment

• First-line preventive medications include propranolol, metoprolol, or topiramate for patients with frequent migraine with aura 1
• Preventive treatments for migraine with aura are the same as those used for migraine without aura, though evidence is limited from trials specifically dedicated to migraine with aura 2
• Evaluate treatment response within 2-3 months using headache calendars to track attack frequency, severity, and medication use 1

Diagnostic Pitfalls to Avoid

When to Suspect Alternative Diagnoses

• Sudden (non-gradual) onset of neurological symptoms suggests TIA or stroke rather than aura and requires emergency evaluation 2, 4
• Absence of visual symptoms, simultaneous (rather than successive) neurological symptoms, or symptoms corresponding to a specific vascular territory warrant urgent stroke workup 2
• Aura duration exceeding one hour, late onset of aura (new onset in older adults), or dramatic increase in aura frequency should prompt neuroimaging 2
• Consider epilepsy in the differential, particularly if consciousness is altered or symptoms are stereotyped 4

Recognizing Typical Aura Features

• Each aura symptom lasts 5-60 minutes with gradual development 5
• At least one symptom is unilateral and at least one is positive (e.g., visual scintillations, not just scotoma) 5
• Visual aura occurs in over 90% of patients with migraine with aura 2
• When multiple aura symptoms occur, they typically follow in succession: visual, then sensory, then aphasic 2
• Aura is accompanied by or followed by headache within 60 minutes 5

Medication Overuse Warning

• Watch for medication overuse headache, which develops from using acute medications more than twice weekly 1
• Regular overuse for >3 months of non-opioid analgesics on ≥15 days/month or triptans/combination medications on ≥10 days/month meets criteria for medication-overuse headache 5
• Detoxification may be necessary if medication overuse headache develops 3