From the Guidelines
Migraine with aura is best managed with acute treatment using NSAIDs such as ibuprofen (400-600mg) or naproxen (500-550mg) as first-line options, and triptans like sumatriptan (50-100mg orally) or rizatriptan (10mg) as second-line options, according to the most recent guidelines 1. For acute treatment, it is essential to take medications at the first sign of aura.
- NSAIDs like ibuprofen (400-600mg) or naproxen (500-550mg) are effective for mild to moderate migraine attacks.
- Triptans like sumatriptan (50-100mg orally) or rizatriptan (10mg) are first-line options for acute treatment, especially for moderate to severe migraine attacks.
- Combination therapy with triptans and fast-acting NSAIDs can be considered to avert recurrent relapse. For prevention, if migraines occur more than 4 times monthly, consider daily preventive medications like:
- Beta blockers (atenolol, bisoprolol, metoprolol, or propranolol) as first-line medications.
- Topiramate or candesartan as first-line medications.
- CGRP monoclonal antibodies like erenumab (70-140mg monthly injection) as third-line medications. Lifestyle modifications are crucial:
- Maintain regular sleep patterns.
- Avoid known triggers (certain foods, alcohol, stress).
- Stay hydrated.
- Practice stress management techniques. During an attack, rest in a dark, quiet room and apply cold compresses to the forehead. Migraines with aura involve cortical spreading depression, a wave of neuronal depolarization that triggers the visual or sensory disturbances, followed by activation of the trigeminovascular system causing pain and associated symptoms, as supported by recent studies 1.
From the FDA Drug Label
Eletriptan hydrobromide tablets are indicated for the acute treatment of migraine with or without aura in adults.
Migraine headache with aura can be treated with eletriptan hydrobromide tablets. The recommended dose is 20 mg or 40 mg, with a maximum daily dose of 80 mg 2. It is essential to establish a clear diagnosis of migraine before administering eletriptan hydrobromide tablets.
- Key considerations:
- The maximum recommended single dose is 40 mg.
- If the migraine has not resolved by 2 hours after taking eletriptan hydrobromide tablets, or returns after transient improvement, a second dose may be administered at least 2 hours after the first dose.
- The safety of treating an average of more than 3 migraine attacks in a 30-day period has not been established 2.
From the Research
Migraine Headache with Aura
- Migraine with aura (MwA) is a primary headache that affects about 30% of migraine sufferers 3.
- The main questions for the physician caring for the patient who has MwA are: when to use preventive medications, what medications to use in acute and preventive treatment, and whether the aura should be treated 3.
- Controlled trials have demonstrated the efficacy of anticonvulsants in migraine prevention, including valproic acid, topiramate, and gabapentin 4.
- Lamotrigine may be effective at controlling migraine aura, but has not demonstrated effectiveness at controlling migraine headache 4, 5.
- Sumatriptan has been shown to be effective in acute treatment of classical migraine (i.e. migraine with aura) in some studies, but its efficacy may be reduced in subsequent attacks 6.
Treatment Options
- Anticonvulsants, such as valproic acid, topiramate, and gabapentin, are a useful option for the preventive treatment of migraine 4.
- Lamotrigine appears promising for treating attacks of MA and related clinical manifestations because of its high potential of efficacy, low-risk profile, and cost 5.
- Sumatriptan and metoclopramide may be used for acute treatment of migraine, but intravenous valproic acid has been shown to be more effective in some studies 7.
Efficacy of Treatments
- Valproic acid has been shown to be effective in relieving headache from moderate-severe to none-mild within a period of 24 hours 7.
- Lamotrigine has been shown to reduce both the frequency and severity of aura symptoms in multiple conditions and is well tolerated 5.
- Sumatriptan has been shown to be effective in relieving headache 2 h after treatment was given, but its efficacy may be reduced in subsequent attacks 6.