What medication is recommended for a patient with migraines with aura and a history of stroke?

Medication for Migraines with Aura and History of Stroke

In patients with migraine with aura and prior stroke, implement preventive treatments to reduce migraine frequency while strictly avoiding triptans, ergot alkaloids, and all estrogen-containing medications. 1

Acute Treatment Options

Recommended Acute Medications

• NSAIDs (ibuprofen, naproxen) or aspirin should be started as soon as possible during the aura phase to prevent or diminish the subsequent headache. 2
• These medications do not treat the aura itself but target the headache phase that follows. 2

Strictly Contraindicated Acute Medications

• Triptans are contraindicated in patients with prior stroke due to theoretical risks of cerebral vasoconstriction and ischemia, despite conflicting observational evidence. 1
• Ergot alkaloids must be avoided as they are vasoconstrictors that can precipitate ischemic events. 3, 4
• The 2021 AHA/ASA guidelines explicitly state no recommendations can be made for triptan use in this population due to lack of safety data. 1

Preventive Treatment Strategy

First-Line Preventive Options

• Topiramate 50-100 mg daily is a first-line preventive agent with established efficacy. 1, 3
• Sodium valproate 600-1,500 mg daily is another first-line option, though absolutely contraindicated in women of childbearing potential. 1, 3
• Propranolol is appropriate unless beta-blockers might worsen intracranial vasoconstriction in the context of recent infarction. 1

Second-Line Preventive Options

• Amitriptyline 10-100 mg at night is reasonable, avoiding use in patients with heart failure or glaucoma. 1
• Verapamil or other calcium channel antagonists combined with aspirin (if no contraindications) can be considered. 1
• Cyproheptadine represents another alternative preventive option. 1

Third-Line and Newer Agents

• OnabotulinumtoxinA (155-195 units every 12 weeks) for chronic migraine prevention. 1
• CGRP antagonists (erenumab, fremanezumab, eptinezumab) have theoretical vasoconstriction risks, but clinical evidence is lacking. 1
• Notably, fremanezumab is not recommended in patients with history of stroke according to prescribing information. 1

Critical Risk Factor Management

Mandatory Contraceptive Counseling

• All estrogen-containing contraceptives are absolutely contraindicated in women with migraine with aura and prior stroke. 1, 5, 6
• The combination of migraine with aura, estrogen, and prior stroke creates multiplicative stroke risk. 1, 2
• Switch to progestin-only methods (norethindrone, drospirenone pills, levonorgestrel IUD, etonogestrel implant) which carry no increased stroke risk. 5, 6
• Non-hormonal options (copper IUD, barrier methods) are also safe alternatives. 6

Additional Risk Factor Modification

• Smoking cessation is mandatory as the combination of smoking, migraine with aura, and prior stroke dramatically amplifies risk. 1, 4, 7
• Blood pressure optimization is essential, as hypertension with migraine increases ischemic stroke risk 3.1-14.5 fold. 5
• Screen for and address other modifiable vascular risk factors including hyperlipidemia and diabetes. 4, 7

Evaluation for Secondary Causes

Rule Out Stroke Mimics

• Evaluate for CADASIL (cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy). 1, 4
• Consider MELAS (mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes). 1
• Assess for cervical carotid artery dissection (CCAD) and moyamoya disease. 1
• Screen for patent foramen ovale, which may contribute to both migraine and stroke risk. 4

Common Pitfalls to Avoid

• Do not prescribe triptans even if the patient previously responded well to them; the prior stroke changes the risk-benefit calculation entirely. 1
• Do not continue beta-blockers if the patient developed infarction while taking them prophylactically, as they may worsen intracranial vasoconstriction. 1
• Do not assume all CGRP antagonists are safe; fremanezumab specifically lists stroke history as a reason to avoid use. 1
• Do not overlook contraceptive counseling in women of reproductive age, as this represents a modifiable and critical risk factor. 1, 5, 6

Monitoring and Follow-Up

• Evaluate treatment response within 2-3 months using headache calendars to track attack frequency and severity. 1
• Monitor for development of new neurological symptoms that might indicate recurrent stroke or progression of underlying vasculopathy. 6
• Reassess migraine pattern changes, as increased frequency of attacks in migraine with aura further elevates stroke risk. 1