What is the appropriate management for a 46-year-old female patient presenting with a transient left outer eye aura lasting 5-19 minutes, followed by feelings of being 'out of it' and two episodes of transient numbness around the mouth, without subsequent headache or other deficits?

Immediate Referral to Emergency Department/Stroke Center for Urgent Vascular Workup

This patient requires immediate referral to an emergency department affiliated with a stroke center within 24 hours for comprehensive evaluation of possible transient ischemic attack (TIA), as the combination of transient monocular visual symptoms and perioral numbness represents focal neurological deficits in separate vascular territories that carry significant stroke risk. 1

Why This is NOT Migraine with Aura

The clinical presentation argues strongly against migraine with aura and raises serious concern for cerebrovascular disease:

• Absence of headache is atypical: Migraine with aura criteria require that aura be accompanied by or followed by headache within 60 minutes, which did not occur in this patient 2, 3
• Multiple neurological territories involved: The combination of monocular visual symptoms (retinal/ophthalmic artery territory) plus perioral numbness (different vascular distribution) suggests cerebrovascular disease rather than migraine 1
• Transient monocular visual loss (amaurosis fugax) is a form of retinal TIA: The retina is part of the central nervous system, and retinal ischemia constitutes CNS infarction 1
• Age and presentation: At 46 years old with inaugural neurological symptoms affecting multiple territories, vascular etiology must be excluded first 4

Critical Stroke Risk Timeline

The risk of ischemic stroke is highest within the first 7 days after transient symptoms and remains elevated for 30 days, making urgent evaluation mandatory rather than optional 1, 2:

• Stroke risk within 1-4 weeks ranges from 3-6% after retinal artery events 2
• Concurrent silent brain infarction is present in 19-25% of patients with retinal artery occlusion on diffusion-weighted MRI 2, 1
• Up to 70% of patients with symptomatic retinal artery occlusion have clinically significant carotid stenosis 2, 1

Required Urgent Diagnostic Workup

The patient needs the following evaluations emergently (within 24 hours) 2, 1:

• Diffusion-weighted MRI of brain (not CT): Detects silent brain infarction that CT misses; 20-24% of patients with retinal artery occlusion have concurrent cerebral infarction on MRI 2, 1
• Carotid duplex ultrasound: Essential to identify carotid stenosis ≥50% requiring immediate intervention 2, 1
• CTA or MRA if carotid ultrasound equivocal: To definitively assess for high-grade stenosis 1
• Cardiac evaluation: ECG and echocardiography to exclude cardioembolic source 2
• ESR/CRP: To exclude giant cell arteritis (GCA), which is an ophthalmologic emergency in patients over 50 years old 2

Immediate Management Steps

While arranging urgent referral 1:

• Initiate aspirin 75-325 mg daily if no contraindications, as antiplatelet therapy is indicated for documented amaurosis fugax 1
• Consider dual antiplatelet therapy (aspirin plus clopidogrel for 21 days) if symptoms suggest minor stroke, followed by long-term single agent 1
• Exclude GCA immediately: If any symptoms of temporal tenderness, jaw claudication, weight loss, or proximal myalgia, start high-dose corticosteroids (40-60 mg/day prednisone) emergently before temporal artery biopsy 2, 1

Critical Pitfalls to Avoid

• Delaying referral beyond 24 hours is the most critical error: Stroke risk is maximal in the first week, and this window cannot be missed 1, 2
• Attributing symptoms to "migraine without headache" without vascular workup is dangerous: Transient monocular vision loss requires carotid imaging regardless of other considerations 1
• Ordering CT instead of MRI: CT is insufficient and misses silent infarctions visible on diffusion-weighted MRI sequences 2, 1
• Assuming benign etiology because symptoms resolved: Complete symptom resolution is characteristic of both TIA and migraine aura, making clinical distinction unreliable without imaging 4, 5

Why Migraine Aura Criteria Are Not Met

According to ICHD-3 criteria, migraine with aura requires 2:

• At least 2 attacks (this is the first episode) 2
• Aura accompanied by or followed by headache within 60 minutes (absent here) 2, 3
• Gradual spread over ≥5 minutes with positive phenomena (scintillations) - while the visual symptoms lasted 5-19 minutes, the addition of perioral numbness in a separate territory is atypical 2, 3

The absence of headache, inaugural presentation, and involvement of multiple vascular territories make TIA the diagnosis that must be excluded urgently before considering any benign explanation. 1, 4