Treatment of Migraine Aura Symptoms
Start NSAIDs (ibuprofen 400-800mg or naproxen sodium 275-550mg) immediately when aura symptoms begin to prevent or diminish the subsequent headache phase, and never use triptans during the aura itself. 1, 2
Acute Treatment During Aura Phase
First-Line: NSAIDs or Aspirin
- Initiate NSAIDs or aspirin as soon as aura symptoms appear to abort or diminish the headache that typically follows within 60 minutes 2, 3
- Recommended dosing: ibuprofen 400-800mg every 6 hours or naproxen sodium 275-550mg 1
- These medications do not treat the aura itself but target the impending headache phase 3
Critical Contraindication: No Triptans During Aura
- Triptans are contraindicated during the aura phase due to theoretical concerns about vasoconstriction during cortical hypoperfusion 1, 2
- Triptans are ineffective for aura symptoms themselves 1
- Wait until the headache phase begins before considering triptan use 1
Treatment After Aura (Headache Phase)
When NSAIDs Fail
- If NSAIDs or aspirin fail to prevent headache, use a triptan when the headache begins 3
- Sumatriptan 50-100mg is effective, with maximum 200mg per 24 hours, separated by at least 2 hours between doses 1
- The efficacy of sumatriptan is unaffected by presence of aura 4
Medication Overuse Warning
- Limit triptan use to prevent medication overuse headache 1, 2
- Medication overuse headache develops from using acute medications more than twice weekly 2
- Using triptans/combination medications on ≥10 days/month for >3 months meets criteria for medication-overuse headache 2
Red Flags Requiring Urgent Neuroimaging
When to Image Immediately
- Obtain urgent MRI brain with diffusion-weighted imaging if visual aura persists beyond 72 hours to rule out stroke or other serious pathology 1
- Normal migraine aura lasts 5-60 minutes maximum 1, 5
- Visual aura symptoms persisting beyond 1 hour are abnormal and warrant investigation 1
- Never dismiss persistent visual symptoms as "just migraine" without imaging 1
Other Concerning Features
- First-time aura with unclear onset (gradual vs. sudden) 3
- Neurological symptoms corresponding to a cerebral vascular territory 3
- Absence of visual aura symptoms or simultaneous neurological symptoms 3
- Late onset of aura or dramatic increase in aura attack frequency 3
Preventive Therapy for Frequent Aura
First-Line Preventive Options
- Initiate daily preventive therapy for patients with frequent migraine with aura 1, 2
- First-line options include:
- Evaluate response within 2-3 months using headache calendars to track attack frequency, severity, and medication use 1, 2
Critical Safety Considerations
Contraceptive Contraindication
- All combined hormonal contraceptives containing estrogen are absolutely contraindicated in women with migraine with aura due to compounded stroke risk 2, 3
- Women with migraine with aura have significantly elevated baseline risk of ischemic stroke 2, 3
- Progestin-only contraceptives are safe alternatives 2
Triptan Contraindications
- Do not use triptans in basilar or hemiplegic migraine 1
- Triptans are contraindicated in patients with history of coronary artery disease, stroke, or peripheral vascular disease 4
Understanding Aura Characteristics
Typical Aura Features
- Visual aura occurs in over 90% of patients with aura 3, 5
- Each aura symptom lasts 5-60 minutes with gradual development 2, 3
- At least one symptom is unilateral and at least one is positive (e.g., visual scintillations, not just scotoma) 2
- Aura is accompanied by or followed by headache within 60 minutes 2
- When multiple aura symptoms occur, they usually follow in succession: visual, then sensory, then aphasic 3
Prolonged Aura
- Approximately 17% of migraine auras are prolonged, and 26% of patients with migraine with aura have experienced at least one prolonged aura 6
- Prolonged auras typically have a higher number of aura symptoms, particularly sensory and/or dysphasic 6
- About 5% of aura symptoms last longer than four hours 5