What is the recommended treatment for moderate migraine with aura?

Treatment for Moderate Migraine with Aura

For moderate migraine with aura, start NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) immediately during the aura phase to prevent or diminish the subsequent headache, then add a triptan (sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg) when the headache begins if NSAIDs alone are insufficient. 1, 2, 3

Acute Treatment Algorithm

During the Aura Phase (Before Headache Onset)

• Initiate NSAIDs or aspirin immediately when aura symptoms begin—not to treat the aura itself, but to preempt or reduce the severity of the impending headache phase 3
• Do NOT administer triptans during the aura phase, as evidence does not support their use before headache onset 1
• The goal is to have the NSAID on board before cortical spreading depression triggers the headache cascade 3

When Headache Begins (After Aura)

• If NSAIDs alone fail or the headache is moderate to severe: Add a triptan immediately when headache pain starts, ideally while pain is still mild 1, 2

• Recommended triptan options for moderate migraine:

  • Sumatriptan 50-100 mg orally (most evidence-based, 70% response rate at 2 hours) 1, 4
  • Rizatriptan 10 mg orally (33% pain-free at 2 hours) 5
  • Eletriptan 40 mg orally (higher efficacy than 20 mg dose) 6

• Combination therapy is superior: Triptan + NSAID together provides better outcomes than either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 2

Specific NSAID Dosing

• Ibuprofen: 400-800 mg at onset 1
• Naproxen sodium: 500-825 mg at onset 1, 2
• Aspirin: 1000 mg at onset 1
• Diclofenac potassium: Alternative first-line NSAID 1

Critical Timing Considerations

• Triptans work best when taken early in the headache phase while pain is still mild, NOT during the aura 1, 2
• Taking triptans during aura has been shown ineffective in controlled trials, though one small open-label study suggested possible benefit 1, 7
• The key distinction: NSAIDs during aura, triptans when headache starts 3

Medication-Overuse Headache Prevention

• Limit all acute medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 2
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 2
• NSAIDs should not be used more than 15 days per month; triptans/combination medications not more than 10 days per month 1

When First-Line Treatment Fails

If One Triptan Fails

• Try a different triptan—failure of one does not predict failure of others 1
• Consider route change: subcutaneous sumatriptan 6 mg provides highest efficacy (59% pain-free at 2 hours) for patients who rapidly reach peak intensity or have vomiting 1, 2

If All Triptans Fail

• Third-line options include lasmiditan (ditan), ubrogepant, or rimegepant (gepants), though availability is limited 1, 2
• These newer agents have comparable efficacy to triptans but different mechanisms and side effect profiles 1

Contraindications Requiring Alternative Approach

• Triptans are contraindicated in:

  • Ischemic coronary artery disease, previous MI, or Prinzmetal's angina 6
  • Uncontrolled hypertension 6
  • Peripheral vascular disease or ischemic bowel disease 6
  • Wolff-Parkinson-White syndrome 6
  • History of stroke or TIA 6
  • Hemiplegic or basilar migraine 6

• For patients with triptan contraindications: Use NSAIDs alone or consider dihydroergotamine (DHE) nasal spray, which has good evidence for efficacy 1, 2

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg or prochlorperazine 25 mg if nausea is present, as these provide synergistic analgesia beyond antiemetic effects 1, 2
• Antiemetics can be given 20-30 minutes before NSAIDs to enhance absorption and outcomes 2

Common Pitfalls to Avoid

• Do not wait for severe pain to develop—early treatment during mild pain phase dramatically improves triptan efficacy 1, 2
• Do not give triptans during aura—wait until headache begins 1, 3
• Do not combine triptans with ergotamines within 24 hours 6
• Do not use triptans within 72 hours of potent CYP3A4 inhibitors (ketoconazole, itraconazole, ritonavir, clarithromycin) 6
• Do not establish patterns of frequent acute medication use—this creates medication-overuse headache and requires transition to preventive therapy 1, 2

When to Escalate to Preventive Therapy

• Initiate preventive therapy if:
  • Using acute medications more than 2 days per week 2
  • Having ≥4 migraine days per month with significant disability 1
  • Acute treatments are contraindicated or consistently ineffective 1
  • Patient has hemiplegic or basilar migraine variants 1