Treatment of Ocular Migraine
For ocular migraine (retinal migraine), treat acute attacks with NSAIDs like ibuprofen as first-line therapy, advancing to triptans if NSAIDs are inadequate, and consider preventive therapy with beta-blockers, topiramate, or propranolol if attacks are frequent or disabling.
Understanding Ocular Migraine
Ocular migraine (also called retinal migraine) presents with transient monocular visual loss and requires recognition to provide appropriate treatment and avoid unnecessary testing 1. This differs from typical migraine with visual aura, which affects both eyes.
Acute Treatment Approach
First-Line Acute Therapy
- Start with NSAIDs: Ibuprofen, acetylsalicylic acid, or diclofenac potassium are first-line medications with proven efficacy 2, 3
- Treat early: Medications should be taken early in the attack when symptoms are still mild for best results 2
- Paracetamol has less efficacy and should only be used if NSAIDs are not tolerated 2
Second-Line Acute Therapy
- Advance to triptans if NSAIDs provide inadequate relief 2, 3
- All triptans have well-documented effectiveness, though availability varies by country 2
- If one triptan fails, try another—different triptans may still provide relief despite failure of the first 2
- For rapidly escalating symptoms or significant nausea/vomiting, consider non-oral triptan formulations (nasal spray or subcutaneous injection) 2
Combination Therapy
- If monotherapy fails, combine NSAIDs with triptans (e.g., sumatriptan/naproxen combination) 2
- Add an antiemetic if nausea or vomiting is present 2
Third-Line Options
- For severe attacks unresponsive to oral therapy, consider parenteral ketorolac (60 mg IM, maximum 120 mg/day for no more than 5 days) or prochlorperazine (0.15 mg/kg IV, maximum 10 mg) 4, 5
Preventive Treatment
When to Consider Prevention
- Frequent attacks: Two or more attacks per month 6
- Disabling attacks: Prolonged attacks with poor response to acute treatment that reduce quality of life 6
- Medication overuse: Using acute medications more than twice weekly or more than 10 days per month 5, 3, 6
First-Line Preventive Medications
- Beta-blockers (propranolol, metoprolol, atenolol, or bisoprolol): Particularly useful if hypertension or tachycardia coexists 5, 7
- Topiramate: Effective for episodic and chronic migraine; may cause weight loss but watch for cognitive effects 2, 5, 7
- Propranolol: Specifically recommended in pediatric guidelines 2
Second-Line Preventive Options
- Amitriptyline: Especially when combined with cognitive behavioral therapy; useful if comorbid depression or tension-type headaches exist 2, 7
- Candesartan: Consider in hypertensive patients 5, 7
Important Contraindications
- Avoid valproate/divalproex in women of childbearing age due to teratogenic effects; if used, ensure effective contraception and folate supplementation 2, 5
Critical Pitfalls to Avoid
- Medication overuse headache: Do not use acute medications more than 10 days per month to prevent transformation to chronic daily headache 4, 5, 3
- Delayed treatment: Early treatment during attacks is crucial—waiting until pain is severe reduces efficacy 2
- Giving up after one triptan fails: Different triptans have varying efficacy in individual patients; trial multiple agents before declaring triptan failure 2
- Unnecessary testing: Recognize ocular migraine clinically to avoid excessive workup 1
Lifestyle Modifications
- Maintain regular sleep schedules and meal times 2, 5, 3
- Identify and avoid specific triggers when self-evident (though true trigger factors are often obvious and predisposing factors should not be conflated with aggravating factors) 2
- Ensure adequate hydration 5, 3
- Implement stress management techniques 3, 7