What is the best course of action for a 46-year-old female with a history of migraine with auras, Attention Deficit Hyperactivity Disorder (ADHD) managed with Adderall (amphetamine and dextroamphetamine), iron deficiency (low ferritin level) due to heavy periods, and abnormal endometrium thickening, who has recently experienced aura without headache and transient numbness?

Urgent Neurological Evaluation Required for Atypical Aura Presentation

This patient requires immediate neurological evaluation to rule out transient ischemic attack (TIA) or other serious cerebrovascular events, as the combination of monocular visual symptoms, transient numbness, and prolonged post-event cognitive impairment ("feeling out of it") are red flags that cannot be dismissed as typical migraine aura. 1, 2

Critical Differential Diagnosis Considerations

Why This May NOT Be Migraine Aura

• Monocular visual symptoms are concerning: True migraine with visual aura affects both eyes or both visual fields simultaneously (binocular), not one eye. Monocular symptoms suggest retinal migraine or, more worrisome, retinal artery pathology or TIA 1, 2

• Transient numbness occurring hours after visual symptoms: Migraine aura symptoms typically occur in succession with gradual spread over ≥5 minutes, not separated by hours. This temporal pattern raises concern for multiple discrete vascular events 1

• Prolonged cognitive impairment: While post-aura symptoms can occur, "feeling out of it for the rest of the day" is atypical and warrants investigation for cerebrovascular insufficiency 1

• Aura without headache in perimenopause: While late-life migraine accompaniments (aura without headache) can occur, new-onset or changing aura patterns at age 46 require exclusion of stroke mimics, especially given multiple cardiovascular risk factors 1, 2

Compounding Risk Factors Present

• Adderall use: Amphetamines can cause vasoconstriction and increase cardiovascular risk, potentially contributing to both migraine symptoms and cerebrovascular events 3

• Iron deficiency (ferritin 5): Severe iron deficiency is associated with increased migraine frequency and severity, and may worsen ADHD symptoms requiring higher stimulant doses 4, 3, 5, 6

• Perimenopause with abnormal uterine bleeding: Hormonal fluctuations can trigger migraine changes, but also represent a period of changing cardiovascular risk 6

Immediate Action Steps

1. Urgent Neurological Referral

• Obtain brain MRI with and without contrast plus MRA of head and neck to evaluate for structural lesions, white matter changes, or vascular abnormalities that could explain monocular visual symptoms and transient numbness 1

• Consider ophthalmology consultation if retinal migraine is suspected, as monocular visual symptoms require evaluation for retinal artery pathology 2

2. Cardiovascular Risk Assessment

• Discontinue or reassess Adderall: Given the atypical neurological symptoms and cardiovascular concerns, the risk-benefit of continued stimulant therapy must be reevaluated. Iron supplementation may allow for lower stimulant doses or alternative ADHD management 7, 3

• Check blood pressure: Stimulants combined with migraine with aura increase stroke risk, particularly if hypertension is present 2

3. Aggressive Iron Repletion

• Initiate ferrous sulfate 80 mg daily (or equivalent elemental iron): Ferritin of 5 represents severe iron deficiency that contributes to both migraine severity and ADHD symptom burden. Iron supplementation has shown effectiveness comparable to stimulants for ADHD (particularly inattentive subtype) and may reduce migraine frequency 4, 3, 5, 6

• Target ferritin >30 ng/mL: Studies show inverse correlation between ferritin levels and ADHD symptom severity, with levels <30 ng/mL associated with worse outcomes 4, 3, 5

• Address underlying cause: Coordinate with gynecology regarding abnormal uterine bleeding and endometrial thickening to prevent recurrent iron deficiency 6

If Migraine Diagnosis Is Confirmed After Workup

Acute Treatment Modifications

• NSAIDs or aspirin at aura onset: Initiate as soon as aura symptoms appear to abort or diminish subsequent headache 2

• Avoid triptans during aura phase: Due to theoretical vasoconstriction concerns during cortical hypoperfusion, triptans should only be used once headache phase begins (if it occurs) 2

• Limit acute medication use to <2 days per week: To prevent medication overuse headache, which develops from non-opioid analgesics used ≥15 days/month 1, 2

Preventive Therapy Considerations

Given the recurrence of aura after 5-year remission, preventive therapy should be considered:

• First-line options: Propranolol 80-160 mg daily, metoprolol 50-200 mg daily, or topiramate 50-100 mg daily 2

• Avoid topiramate initially: Given cognitive side effects that may worsen ADHD symptoms and the "feeling out of it" she already experiences 2

• Beta-blockers may be preferred: Can address both migraine prevention and any stimulant-induced tachycardia or hypertension 2

Absolute Contraindication

• No estrogen-containing contraceptives: All combined hormonal contraceptives are absolutely contraindicated in women with migraine with aura due to compounded stroke risk. Progestin-only contraceptives are safe alternatives 2

Common Pitfalls to Avoid

• Do not assume this is benign migraine recurrence: The monocular nature, temporal pattern, and associated symptoms require stroke workup first 1, 2

• Do not overlook the iron deficiency: Ferritin of 5 is severe and contributes to multiple symptoms. This must be aggressively treated 4, 3, 5, 6

• Do not continue stimulants without reassessment: The combination of Adderall, migraine with aura, and new neurological symptoms warrants careful risk-benefit analysis 7, 3

• Do not delay evaluation: Transient neurological symptoms require urgent assessment, not watchful waiting 1